Smallpox Anthrax Pneumonic
Botulism Tularemia Viral Hemorrhagic
Epidemiologic clues and warning signs Multiple cases of what may initially resemble "adult chickenpox"; fever; malaise; painful, centrifugal, pustular rash Sudden appearance of multiple cases of severe flu-like illness with fulminant course and high mortality Sudden appearance of multiple patients with fever, cough, SOB, hemoptysis, and chest pain; GI symptoms common; fulminant course and high mortality Outbreak of large number of cases with acute, afebrile, descending paralysis with prominent bulbar palsies; death by respiratory failure Sudden appearance of multiple patients in urban setting with URT symptoms and bronchitis rapidly progressing to pleuropneumonia with high mortality Early:abrupt onset fever myalgia, and prostration with mild decrease in BP, flushing, and petechiae; Later:shock, hemorrhage, neurologic changes, vomiting, and diarrhea Diagnostic studies Guarnieri bodies seen under oil CXR:Widened mediastinum pleural effusion; Peripheral blood smear: gram-positive bacilli on unspun or buffy coat smear, CSF: gram-positive bacilli CXR:Pulmonary infiltrates or consolidation; Physical exam: Infrequent cervical bubo and purpuric skin lesions Clinical: Afebrile descending paralysis with diplopia, dysarthria, dysphagia, and/or dysphonia; clear sensorium; toxin in blood, GI tract, or stool CXR:Bilateral pulmonary infiltrates or pleural effusions and pneumonia Neutrophilia; DIC in Ebola and Marburg; jaundice in yellow fever Microbiology Electron microscopy Blood culture with large gram-positive organism of Bacillus species Gram-negative bacilli with bipolar staining on Wright, Giemsa, or Wayson's stain Gram-negative coccobacilli in sputum, blood, or tracheobronchial secretions; DFA Virologic studies: ELISA or reverse transcriptase PCR; viral isolation in biocontainment laboratory Pathology Lesions mainly in skin and mucous membranes; secondary bacterial infection; death occurs from toxemia associated with circulating immune complexes and variola antigens Hemorrhagic mediastinitis; hemorrhagic thoracic lymphadenitis; hemorrhagic meningitis Lobular exudation; bacillary aggregation; necrotic areas in pulmonary parenchyma Irreversible binding to cholinergic synapses with enzymatic blocking of acetylcholine release; recovery results from sprouting of new motor axon twigs (weeks to months) Pleural effusion; lobar pneumonia or patchy infiltrates; in other routes of infection, patients may have skin, eye, pharyngeal, or GI disease Neutrophilia, hypofibrinogenemia, thrombocytopenia, and microangiopathic hemolytic anemia; vascular permeability, abnormalities in circulatory regulation Incubation period 12-14 days Limited info; from the accidental outbreak in Sverdlovsk, 2-43 days before clinical illness developed 1-6 days, usually 2-4 days Foodborne: 2 hrs to 8 days; Airborne: 12-72 hours (?) 1-14 days (inhalational exposure) 2 days to 3 weeks Clinical pearls Unlike chickenpox, lesions in any one part of the body are in the same stage of development Radiographically, does not present as a bronchopneumonia, unlike pneumonic plague or tularemia; however, 3 of 8 patients in the US bioterrorism outbreak had pulmonary infiltrates Hemoptysis suggests plague rather than anthrax Differs from other flaccid paralyses in its prominent CN palsies disproportionate to milder weakness and hypotonia below the neck; also, no sensory losses Wide group of viral agents with a broad range of symptoms and risk of spread to contacts. Hepatitis prominant with yellow fever
SOB = Shortness of breath, GI = gastrointestinal, URT = upper respiratory tract, BP = blood pressure, CXR = chest x-ray, CSF = cerebrospinal fluid, DIC = disseminated intravascular coagulation, DFA = direct fluorescent antibody, ELISA = enzyme-linked immunosorbent assay, PCR = polymerase chain reaction, CN = cranial nerve.
Smallpox Anthrax Pneumonic
Botulism Tularemia Viral Hemorrhagic
Reporting possible attack Notify Infectious Disease Service; Notify AOD; Notify local public health department; CDC Emergency Preparedness and Response: (770-488-7100); Notify FBI and police Notify Infectious Disease Service; Notify AOD; Notify local public health department; CDC Emergency Preparedness and Response: (770-488-7100); Notify FBI and police Notify Infectious Disease Service; Notify AOD; Notify local public health department; CDC Emergency Preparedness and Response: (770-488-7100); Notify FBI and police Protection of staff, patients, and environment Decontamination: clothing and bedding is autoclaved or laundered in hot water with bleach; disinfectants for standard infection control; Infection control: airborne precautions, gloves, gowns, and masks; VIG for immunosuppression Decontamination; clothing and skin washed with soap and water; Infection control: standard precautions and no isolation required No decontamination; Infection control: In hospital, droplet precautions x first 48 hours of antibiotic treatment; close contacts of victims not taking antibiotics do not require isolation-if symptoms occur in 7 days, treat Decontamination; clothing and skin washed with soap and water; contaminated surfaces cleaned with 0.1% hypochlorite bleach; Infection control: standard precautions; isolation not required No decontamination; Infection control: Isolation is not recommended (no human to human transmission); standard precautions Decontamination; soiled linens autoclaved or incinerated; environmental surfaces cleaned and disinfected with standard procedures; Infection control: contact precautions, airborne precautions may be necessary if coughing or vomiting or bleeding profusely Treatment of victims Supportive therapy and antibiotics for secondary bacterial infections Fluoroquinolones, tetracyclines, or penicillins for 60 days Gentamicin or streptomycin, fluoroquinolones, tetracyclines, chloramphenicol Supportive care: for weeks to months; passive immunization with equine antitoxin Contained casualty situation: parenteral streptomycin, gentamicin, doxycycline, ciprofloxacin; Mass: doxycycline or ciprofloxacin Supportive care; Ribavirin in some VHF patients (Lassa and South American VHF ) Prophylaxis Vaccinate staff, patients, and general population Fluoroquinolones; vaccine if available Vaccine: No Doxycycline or ciprofloxacin; vaccine not recommended Vaccine for yellow fever
AOD = Administrator on duty, VIG = vaccinia immune globulin, VHF = viral hemorrhagic fever.