Pediatric Plague Clinical Presentation

Updated: Aug 16, 2021
  • Author: Vinod K Dhawan, MD, FACP, FRCPC, FIDSA; Chief Editor: Russell W Steele, MD  more...
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The incubation period of plague is 3-4 days (range, hours to 10 d). Sore throat may be the only complaint of patients with plague pharyngitis.

Bubonic plague

Bubonic plague, resulting from the bite of an infected flea, accounts for approximately 80%–85% of cases.

Patients complain of fever with abrupt onset and other constitutional symptoms. These symptoms usually manifest 3-6 days after contracting the organism but may appear in the first day or be delayed for longer than a week. Clinical manifestations of plague are the same for children and adults.

Fever with chills is virtually universal. Temperatures typically range from 38.5-40ºC.

Headache, malaise, and weakness are all very common.

An area of focal painful lymphadenopathy (bubo) develops and progresses during the first few days of illness (see the image below).

Inguinal bubo on upper thigh of a person with bubo Inguinal bubo on upper thigh of a person with bubonic plague. Image courtesy of the Centers for Disease Control and Prevention (CDC).

This bubo rapidly becomes very tender and can measure up to 10 cm. Over time, fluctuance develops, and the buboes often suppurate and drain. The most common site affected is the groin, followed by the axillary and cervical lymph nodes. Intra-abdominal buboes may present as an acute abdomen.

Nausea, vomiting, diarrhea, and abdominal pain are common. These, as well as the constitutional symptoms of headache and malaise, are thought to result from the gram-negative septicemia caused by Y pestis.

Patients with plague may complain of sleep disturbance, vertigo, and loss of memory. Weakness, delirium, stupor, ataxia, and speech disorders may also occur. These manifestations are due to the effects of endotoxin on the brain. Meningitis may develop. Children younger than 15 years appear to be more susceptible to meningitis.

Septicemic plague

Constitutional symptoms are similar to bubonic plague. Absence of palpable buboes differentiates the 2 forms.

Meningitis is 4 times more common in this form of the disease than with bubonic plaque. Additionally, pneumonic plaque occurs twice as often in septicemic plaque than in the bubonic form.

Patients with septicemia are often older than 60 years. They are usually less febrile, but mortality is higher.

Bacteremia may be so great that organisms can be visualized on peripheral smears.

Pneumonic plague

Primary pneumonic plague is a fulminant infection, occurring in approximately 3% of plague patients. It results from inhalation of infectious droplets. Secondary pneumonic plague results from the spread of Y. pestis to the lungs in patients with bubonic or septicemic infection.

Patients primarily manifest fever and respiratory symptoms, including cough, hemoptysis, and chest pain. Tachypnea and dyspnea are also common.

Thin, watery, blood-tinged sputum becomes frankly bloody and mucopurulent as the disease rapidly progresses.

Plague bacillus can be cultured from sputum, and disease transmission is thought to occur up to 2 meters from a patient who may be coughing.


Physical Examination

Generally, patients with any form of plague are toxic in appearance. Apprehension and tachycardia are also common.

All patients are febrile with chills.

A large bubo is palpable in the groin, axilla, or neck of patients with bubonic plague. The mass is fixed, edematous, exquisitely tender, and often surrounded by an area of erythema.

Intra-abdominal buboes may be accompanied by tenderness, guarding, and other peritoneal signs. Hepatomegaly can be present.

Septicemic patients present with tachycardia, tachypnea, and hypotension. Systolic blood pressures are usually less than 100 mm Hg. Differentiation of patients with septicemic plague from patients with other types of gram-negative sepsis is often difficult due to the similarity of signs and symptoms.

Patients with pneumonic plague manifest cough productive of bloody sputum, tachypnea, and dyspnea.

Fever and meningismus accompany plague meningitis.

Patients with plague pharyngitis resemble those with any other form of bacterial pharyngitis or tonsillitis. Large anterior cervical adenopathy may be appreciated.