Differential diagnosis

I. Bubonic plague
1. Streptococcal and staphylococcal adenitis
2. Tularemia
3. Cat- scratch disease (bartonella =beling to family rickettsia)
also called benign lymphadenopahty, 1st attack on the site of scratch and then LNpathy but only in
one site. Also √ of moderate intox, myalgia and athralgia
4. Mycobact infection
5. Chancroid and strangulated hernia

II. Septic plague

1. Meningococcemia
2. Tularemia
3. Bact endocarditis

III. Pneumonic plague

1. Tularemia
2. CAP (bact)
3. Viral pneumonia (influenza, CMV)

 In bubonic plague, patient usually has incubation period of 2-6 days

 Patient has all the signs of intoxications
 Soon, usually within 24 hours, tenderness and pain occurs in one or more regional LN prox to the
site of inoculation of the plague bact
 Femoral, inguinal LN r most commonly affected
 Axillary and cervical LN are less common
 Pt guards against palpation and limit movement, stretching, and pressure around the bubo
 Surrounding tiss = edematous
 Overlying skin =red-cyanotic, warm and tense
 Distal to the bubo = site of flea bite (seldom seen), marked by small papules, scab or ulcer
 The bubo plague differs fr lymphadenitis fr other causes by its rapid onset, extreme tenderness,
surrounding edema, accompanying signs of toxemia, absent of cellulitis or obvious ascending
lymphangitis
 If treated, in the uncomplicated stage w the appropriate antimicrobial agents, bubonic plague
response quickly with resolution of other systemic manifestation over 2 to 5 days periods
 Bubo – often remain enlarge and tender for a week or more after treatment and infrequently
become fluctuate
 Without effective antimicrobial treatment typical bubonic plague pt manifest an increasingly toxic
state of fever, tachycardia, lethargy leading to frustration, agitation, confusion, convulsion and
delirium
 Mild form of bubonic plague – pestis minor can be found in S. America
pt –ambulatory, mild febrile and √ subacute bubos

Diagnosis

 When plague is suspected, clin specimen should be obtained promptly for microbiology study, CXR is
taken and specific antimicrobial treatment is given
 Blood and other specimens (bubo aspirates, sputum, tracheal wash, swab of the skin lesion, swab of
pharyngeal mucosa and CSF) is inoculated into suitable media  sheep-blood agar
 Smear of each specimen is stained w Giemsa or Gram’s staining
 Direct fluorescence Ab test  useful presumptive diagnostic procedure

Laboratory diagnosis of plague

Methods Material Merit Demerit
1. Bacteriological Blood, bubo aspirates, Absolute confirmed Late detection (> 48 to
methods (contam. sputum, tracheal wash, diagnosis 72 h)
materials should be swab of the skin lesion,
inoculated into suitable swab of pharyngeal
media) mucosa and CSF
2. Biological test (mice Absolute confirmed
and hamster) diagnosis
3. Bacterioscopical Smears of each contam. Rapid diagnosis (after 2 Presumptive diagnosis
methods (Giemsa or materials to 3 h)
Gram’s staining)
4. Direct fluorescence
Ab testing
5. Serological methods Serum, CSF, a serum Assay during Retrospective diagnosis
titer if 128 or > in a antimicrobial treatment
single serum sample id
diagnosis
6. ELISA Serum (detection of To identify Ab in early
IgM and IgG Ab) infection fr post-
vaccintaion Ab
7. PCR Contam. materials Rapid diagnosis Expensive

 Plague pt has typical WBC = 20k or 25k w polymorhonucleocytes

 Leukomoid reaction ( level of leuco) w RBC of 50k or >  in severe infection

Treatment
Drugs Doses Routes of admin
Streptomycin (DOC) Adult 1g q12h IM
Children 15mg/kg q12h* IM
 Gentamycin Adults 1-1.5mg/kg q8h** IM/IV
Children 2.0-2.5mg/kg q8h IM/IV
Infant or newborn 2.5mg/kg 8qh IM/IV
Tetracyclin Adults 0.5g q6h PO
Children >8y 6.25 -12.5mg/kg q6h PO
Doxicyclin Adults 100mg q12h PO/IV
Children >8y and >45kg 100mg q12h PO/IV
Children >8y and <45kg 2.2mg/kg q12h PO/IV
Chloramphenicol Adults 12.5mg/kg q6h*** PO/IV
Children>1y 12.5mg/kg q6h PO/IV

*not to exceed 2g/day

** daily dose should be reduced to 3mg/kg as soon as clinically indicated
***hematogenic values should be monitored closely

Plague control

 Determining the source

 Defining the geo limits if activity
 Establishing active surveillance
 Lab confirmation of cases and isolation of pneumonia cases
 Rapid treatment of cases and others at risk of infection, including close contacts of symptomatic
pneumonic plague
 Control of fleas and rodents in plague-infected areas, in port facilities and on ship