Plague, transmitted by Yersinia pestis, is a rodent zoonosis passed in nature from fleas to humans. In nature, the illness occurs following skin inoculation, transport of the organism to regional lymph nodes, and subsequent dissemination through blood. This bubonic form, characterized by one or more tender lymph nodes, hepatosplenomegaly, skin lesions, and septicemia, has a 50 percent mortality. A WMD attack likely would involve inhalation of the aerosolized organisms. The resulting illness, pneumonic plague, has an untreated mortality of 80 to 100 percent. Two to three days following inhalation, a fulminant illness involving malaise, fever, headache, cough, bloody sputum, shock, and a bleeding diathesis develops. Cardiopulmonary collapse ensues. Laboratory features include patchy infiltrates on chest x-ray, leukocytosis with a left shift, disseminated intravascular coagulation (DIC), and elevated transaminases. The diagnosis is confirmed by Gram stain and culture of lymph node aspirate, blood, sputum, or cerebrospinal fluid (CSF). ELISA or serology is confirmatory. Treatment must be started within 24 h of symptom onset to affect survival. Streptomycin 30 mg/kg per day IM bid for 10 days (or gentamicin if streptomycin is unavailable) or doxycycline 100 mg IV bid for 10 to 14 days is recommended. Chloramphenicol is the antibiotic of choice for patients with meningitis. Prophylaxis of those exposed includes oral ciprofloxacin or doxycycline for 7 days. Secondary transmission is possible for pneumonic plague. Respiratory isolation and droplet precautions are necessary for at least 48 h until sputum cultures are documented as negative.
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