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Recognizing and Responding to an Attack With a Biological Weapon

[South Med J 94(11):1048-1051, 2001. © 2001 Southern Medical Association]


Clues to the Specific Etiologic Agent Used in a Biological Attack


Diagnostic
Features
SmallpoxAnthraxPneumonic
Plague
BotulismTularemiaViral Hemorrhagic
Fever
Epidemiologic clues and warning signsMultiple cases of what may initially resemble "adult chickenpox"; fever; malaise; painful, centrifugal, pustular rashSudden appearance of multiple cases of severe flu-like illness with fulminant course and high mortalitySudden appearance of multiple patients with fever, cough, SOB, hemoptysis, and chest pain; GI symptoms common; fulminant course and high mortalityOutbreak of large number of cases with acute, afebrile, descending paralysis with prominent bulbar palsies; death by respiratory failureSudden appearance of multiple patients in urban setting with URT symptoms and bronchitis rapidly progressing to pleuropneumonia with high mortalityEarly:abrupt onset fever myalgia, and prostration with mild decrease in BP, flushing, and petechiae; Later:shock, hemorrhage, neurologic changes, vomiting, and diarrhea
Diagnostic studiesGuarnieri bodies seen under oilCXR:Widened mediastinum pleural effusion; Peripheral blood smear: gram-positive bacilli on unspun or buffy coat smear, CSF: gram-positive bacilliCXR:Pulmonary infiltrates or consolidation; Physical exam: Infrequent cervical bubo and purpuric skin lesionsClinical: Afebrile descending paralysis with diplopia, dysarthria, dysphagia, and/or dysphonia; clear sensorium; toxin in blood, GI tract, or stoolCXR:Bilateral pulmonary infiltrates or pleural effusions and pneumoniaNeutrophilia; DIC in Ebola and Marburg; jaundice in yellow fever
MicrobiologyElectron microscopyBlood culture with large gram-positive organism of Bacillus speciesGram-negative bacilli with bipolar staining on Wright, Giemsa, or Wayson's stain Gram-negative coccobacilli in sputum, blood, or tracheobronchial secretions; DFAVirologic studies: ELISA or reverse transcriptase PCR; viral isolation in biocontainment laboratory
PathologyLesions mainly in skin and mucous membranes; secondary bacterial infection; death occurs from toxemia associated with circulating immune complexes and variola antigensHemorrhagic mediastinitis; hemorrhagic thoracic lymphadenitis; hemorrhagic meningitisLobular exudation; bacillary aggregation; necrotic areas in pulmonary parenchymaIrreversible 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 diseaseNeutrophilia, hypofibrinogenemia, thrombocytopenia, and microangiopathic hemolytic anemia; vascular permeability, abnormalities in circulatory regulation
Incubation period12-14 daysLimited info; from the accidental outbreak in Sverdlovsk, 2-43 days before clinical illness developed1-6 days, usually 2-4 daysFoodborne: 2 hrs to 8 days; Airborne: 12-72 hours (?)1-14 days (inhalational exposure)2 days to 3 weeks
Clinical pearlsUnlike chickenpox, lesions in any one part of the body are in the same stage of developmentRadiographically, does not present as a bronchopneumonia, unlike pneumonic plague or tularemia; however, 3 of 8 patients in the US bioterrorism outbreak had pulmonary infiltratesHemoptysis suggests plague rather than anthraxDiffers 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.


Response to Specific Biological Weapons


Type of
Response
SmallpoxAnthraxPneumonic
Plague
BotulismTularemiaViral Hemorrhagic
Fever
Reporting possible attackNotify Infectious Disease Service; Notify AOD; Notify local public health department; CDC Emergency Preparedness and Response: (770-488-7100); Notify FBI and policeNotify Infectious Disease Service; Notify AOD; Notify local public health department; CDC Emergency Preparedness and Response: (770-488-7100); Notify FBI and policeNotify Infectious Disease Service; Notify AOD; Notify local public health department; CDC Emergency Preparedness and Response: (770-488-7100); Notify FBI and policeNotify Infectious Disease Service; Notify AOD; Notify local public health department; CDC Emergency Preparedness and Response: (770-488-7100); Notify FBI and policeNotify Infectious Disease Service; Notify AOD; Notify local public health department; CDC Emergency Preparedness and Response: (770-488-7100); Notify FBI and policeNotify 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 environmentDecontamination: 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 immunosuppressionDecontamination; clothing and skin washed with soap and water; Infection control: standard precautions and no isolation requiredNo 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, treatDecontamination; clothing and skin washed with soap and water; contaminated surfaces cleaned with 0.1% hypochlorite bleach; Infection control: standard precautions; isolation not requiredNo decontamination; Infection control: Isolation is not recommended (no human to human transmission); standard precautionsDecontamination; 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 victimsSupportive therapy and antibiotics for secondary bacterial infectionsFluoroquinolones, tetracyclines, or penicillins for 60 daysGentamicin or streptomycin, fluoroquinolones, tetracyclines, chloramphenicolSupportive care: for weeks to months; passive immunization with equine antitoxinContained casualty situation: parenteral streptomycin, gentamicin, doxycycline, ciprofloxacin; Mass: doxycycline or ciprofloxacinSupportive care; Ribavirin in some VHF patients (Lassa and South American VHF )
ProphylaxisVaccinate staff, patients, and general populationFluoroquinolones; vaccine if availableVaccine: No Doxycycline or ciprofloxacin; vaccine not recommendedVaccine for yellow fever

AOD = Administrator on duty, VIG = vaccinia immune globulin, VHF = viral hemorrhagic fever.