CBRNE - Plague Workup

  • Author: Susan E Dufel, MD, FACEP; Chief Editor: Robert G Darling, MD, FACEP   more...
 
Updated: Jun 3, 2011
 

Laboratory Studies

Complete blood count

WBC count may be markedly elevated to levels of 20,000 or greater.

Usually, a shift to the left is noted. In late septic shock, the WBC count may be low.

Urinalysis

Urinalysis may demonstrate gross hematuria, RBC casts, and proteinuria. Rapid urine dipstick tests have been developed to screen for Ypestis antigen and can be used in the field for rapid identification during outbreak situations.

Arterial blood gas

Arterial blood gas level may reveal hypoxia and/or acidosis.

Y pestis coccobacillus identified in peripheral smear

In up to 20% of patients according to some studies

Gram stain

Gram stain may identify the gram-negative, pleomorphic coccobacillus.

Gram stain can be performed on bubo aspirate, sputum, and blood.

In 70% of patients, the gram-negative, bipolar-stained coccobacillus is visualized if present. When stained with Wayson or Giemsa stain, a bipolar safety pin structure may be identified. While Wright stain often demonstrates this characteristic appearance, shown in the image below, Giemsa and Wayson stains most consistently highlight this pattern.

Wright stain peripheral blood smear of patient witWright stain peripheral blood smear of patient with septicemic plague demonstrating bipolar, safety pin staining of Yersinia pestis. While Wright stain often demonstrates this characteristic appearance, Giemsa and Wayson stains most consistently highlight this pattern. Courtesy of Jack Poland, PhD, CDC, Fort Collins, CO.

Cultures of blood, sputum and bubo aspirate

The plague bacillus grows readily on most culture media.

Growth is slow and may require more than 48 hours before identification of colonies is possible.

Optimal growth occurs at 28°C.

Blood culture results are positive in 85-96% of patients.

Bubo aspirate culture results are positive in 80-85% of patients.

Sputum culture results are positive only if lung involvement is present.

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Imaging Studies

Chest radiography

  • Pneumonic plague should produce alveolar infiltrates with or without hilar lymphadenopathy.
  • Bilateral consolidation may be evidenced.
  • The radiograph below shows a patient with plague pneumonia.Right-side middle and lower lobe involvement in a Right-side middle and lower lobe involvement in a patient with plague pneumonia. No chest radiograph pattern is characteristic of plague, but bilateral interstitial infiltrates are most commonly seen. Courtesy of Jack Poland, PhD, CDC, Fort Collins, CO.
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Other Tests

Specialized diagnostic testing is available at some laboratories, such as state health departments or the Centers for Disease Control and Prevention (CDC).

A new F1 antigen rapid diagnostic test using monoclonal antibodies has recently shown promise in the early detection of the plague.

Y pestis fluorescent antibody stain

This stain is performed on blood, sputum, or bubo aspirate samples.

It may provide rapid diagnosis if available.

If unavailable, send specimens to the CDC, Plague Branch, PO Box 2087, Fort Collins, CO 80522.

Y pestis fluorescent antibody titer

Acute and convalescent passive hemagglutination (PHA) titers should be taken 10 days apart.

A 4-fold difference or a single convalescent PHA titer of 1:16 is evidence of infection.

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Procedures

Needle aspiration of a bubo

The diagnosis may be made by Gram stain and culture of the aspirate.

One may attempt aspiration even if the lymph node is hard and nonfluctuant.

Infusion of 1-3 cm3 of normal saline in the aspiration site prior to aspiration may prove beneficial.

Strict contact and respiratory precautions must be practiced to avoid spreading this highly contagious agent.

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Contributor Information and Disclosures
Author

Susan E Dufel, MD, FACEP  Program Director, Associate Professor, Department of Traumatology and Emergency Medicine, Division of Emergency Medicine, University of Connecticut School of Medicine

Susan E Dufel, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Deirdre Cronin, MD  Resident Physician, Department of Emergency Medicine, University of Connecticut School of Medicine, Farmington

Disclosure: Nothing to disclose.

Specialty Editor Board

Dan Danzl, MD  Chair, Department of Emergency Medicine, Professor, University of Louisville Hospital

Dan Danzl, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Kentucky Medical Association, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Eric L Weiss, MD, DTM&H  Medical Director, Office of Service Continuity and Disaster Planning, Fellowship Director, Stanford University Medical Center Disaster Medicine Fellowship, Chairman, SUMC and LPCH Bioterrorism and Emergency Preparedness Task Force, Clinical Associate Progressor, Department of Surgery (Emergency Medicine), Stanford University Medical Center

Eric L Weiss, MD, DTM&H is a member of the following medical societies: American College of Emergency Physicians, American College of Occupational and Environmental Medicine, American Medical Association, American Society of Tropical Medicine and Hygiene, Physicians for Social Responsibility, Southeastern Surgical Congress, Southern Association for Oncology, Southern Clinical Neurological Society, and Wilderness Medical Society

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Robert G Darling, MD, FACEP  Adjunct Clinical Assistant Professor of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine; Associate Director, Center for Disaster and Humanitarian Assistance Medicine

Robert G Darling, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, American Telemedicine Association, and Association of Military Surgeons of the US

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Demetres G Velendzas, MD, and Thomas W McGovern, MD, to the development and writing of this article.

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Wright stain peripheral blood smear of patient with septicemic plague demonstrating bipolar, safety pin staining of Yersinia pestis. While Wright stain often demonstrates this characteristic appearance, Giemsa and Wayson stains most consistently highlight this pattern. Courtesy of Jack Poland, PhD, CDC, Fort Collins, CO.
Here a flea is shown with a blocked proventriculus, equivalent to the gastroesophageal region in man. In nature, this flea would develop a ravenous hunger because of its inability to digest the fibrinoid mass of blood and bacteria. Ensuing a biting of the nearest mammal results in clearing of the proventriculus through regurgitation of thousands of bacteria into the bite wound. Courtesy of United States Army Environmental Hygiene Agency.
A suppurative, bubo of the femoral lymph node (shown here), the most common site of the erythematous, tender, swollen, nodes in a plague victim. The next most common lymph node regions involved are the inguinal, axillary, and cervical areas. The child in the image below has an erythematous, eroded, crusting, necrotic ulcer at the presumed primary inoculation site on the left upper quadrant. This type of lesion is uncommonly found in patients with plague. Bubo location is primarily a function of the region of the body in which an infected flea inoculates plague bacilli. Courtesy of Jack Poland, PhD, CDC, Fort Collins, CO.
A suppurative, bubo of the femoral lymph node, shown in the image above, is the most common site of the erythematous, tender, swollen, nodes in a plague victim. The next most common lymph node regions involved are the inguinal, axillary (shown here), and cervical areas. The child in this photo has an erythematous, eroded, crusting, necrotic ulcer at the presumed primary inoculation site on the left upper quadrant. This type of lesion is uncommonly found in patients with plague. Bubo location is primarily a function of the region of the body in which an infected flea inoculates plague bacilli. Courtesy of Jack Poland, PhD, CDC, Fort Collins, CO.
Ecchymoses at the neck base of a girl with plague. Bandage is over the site of a prior bubo aspirate. These lesions probably gave rise to the title line of the children's nursery rhyme "Ring around the rosy." Courtesy of Jack Poland, PhD, CDC, Fort Collins, CO.
Right-side middle and lower lobe involvement in a patient with plague pneumonia. No chest radiograph pattern is characteristic of plague, but bilateral interstitial infiltrates are most commonly seen. Courtesy of Jack Poland, PhD, CDC, Fort Collins, CO.
Rock squirrel in extremis coughing of blood-streaked sputum of pneumonic plague. Courtesy of Ken Gage, PhD, CDC, Fort Collins, CO.
Acral necrosis of nose, lips, fingers (shown here) and toes (image below) and residual ecchymoses over both forearms in a patient recovering from bubonic plague that disseminated to blood and lungs. At one time, the patient's entire body was ecchymotic. Reprinted from McGovern TW, Friedlander AM. Plague. In: Sidell FR, Takafuji ET, Franz DR, eds. Medical Aspects of Chemical and Biological Warfare. Chapter 23 in: Zajtchuk R, Bellamy RF, eds. Textbook of Military Medicine. Washington, DC: US Department of the Army, Office of the Surgeon General, and Borden Institute; 1997: 493. Government publication, no copyright on photos.
Acral necrosis of nose, lips, fingers (image above) and toes (shown here) and residual ecchymoses over both forearms in a patient recovering from bubonic plague that disseminated to blood and lungs. At one time, the patient's entire body was ecchymotic. Reprinted from McGovern TW, Friedlander AM. Plague. In: Sidell FR, Takafuji ET, Franz DR, eds. Medical Aspects of Chemical and Biological Warfare. Chapter 23 in: Zajtchuk R, Bellamy RF, eds. Textbook of Military Medicine. Washington, DC: US Department of the Army, Office of the Surgeon General, and Borden Institute; 1997: 493. Government publication, no copyright on photos.
Bioterrorist Agents. Signs and symptoms. Chart courtesy of North Carolina Statewide Program for Infection Control and Epidemiology (SPICE), copyright University of North Carolina at Chapel Hill, www.unc.edu/depts/spice/bioterrorism.html.
World distribution of plague, 1998. From the Centers for Disease Control and Prevention (CDC), Atlanta, Ga.
 
 
 
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