Bioterrorism Agents – Plague Lesson 8 Scenarios and Questions

Bioterrorism Agents – PlagueBioterrorism Agents – PlagueLesson 8Lesson 8

Scenarios and QuestionsScenarios and Questions

OverviewOverview

• Developing scenarioDeveloping scenario

• Questions to review knowledgeQuestions to review knowledge

• Additional questions for laboratorians and Additional questions for laboratorians and veterinariansveterinarians

Plague Scenario Question 1Plague Scenario Question 1

• Physician in Hartford, ConnecticutPhysician in Hartford, Connecticut

• 35yo male, no underlying35yo male, no underlying

• Fever, chills, malaise, myalgias x 3 daysFever, chills, malaise, myalgias x 3 days

• Productive cough, watery mucoid sputum, Productive cough, watery mucoid sputum, chest pain x 1 daychest pain x 1 day

What would you review to rule out other What would you review to rule out other diseases?diseases?



A.A. Mediastinum on x-rayMediastinum on x-ray

B.B. Progression of diseaseProgression of disease

C.C. Presence of influenzaPresence of influenza

D.D. A and CA and C

E.E. A, B and CA, B and C



E.E. A, B and CA, B and C– Mediastinum on x-rayMediastinum on x-ray– Progression of diseaseProgression of disease– Presence of influenzaPresence of influenza


• Patient deteriorating rapidlyPatient deteriorating rapidly

• No widening of mediastinumNo widening of mediastinum

• No influenza in communityNo influenza in community

• You suspect plagueYou suspect plague

What specimens will you collect for What specimens will you collect for laboratory workup?laboratory workup?



A.A. Pharyngeal swabsPharyngeal swabsB.B. Tracheal wash or aspiratesTracheal wash or aspiratesC.C. Sputum specimensSputum specimensD.D. SerologySerologyE.E. All of the aboveAll of the above



E. All of the aboveE. All of the above– Pharyngeal swabsPharyngeal swabs– Tracheal wash or aspiratesTracheal wash or aspirates– Sputum specimensSputum specimens– SerologySerology


• Laboratory initial reportLaboratory initial report– Small, gram-negative, bipolar-staining, plump Small, gram-negative, bipolar-staining, plump

rods in single, short chainsrods in single, short chains– Catalase positiveCatalase positive– Oxidase and urease negativeOxidase and urease negative– Unable to rule out Unable to rule out Y. pestisY. pestis

• You suspect plague You suspect plague

What is your next step?What is your next step?



A.A. Shut down the hospitalShut down the hospital

B.B. Refer to hospitals reference laboratoryRefer to hospitals reference laboratory

C.C. Call public healthCall public health

D.D. All of the aboveAll of the above



C. Call public healthC. Call public health


• You’ve contacted your hospitals infection You’ve contacted your hospitals infection control practitionercontrol practitioner

What should your infection control What should your infection control practitioner recommend to you?practitioner recommend to you?



A.A. Patient on respiratory precautionsPatient on respiratory precautions

B.B. Close contacts on prophylaxisClose contacts on prophylaxis

C.C. Names of those within 6 feet of patientNames of those within 6 feet of patient

D.D. A and CA and C



D.D. A and CA and C– Patient on respiratory precautionsPatient on respiratory precautions– Names of those within 6 feet of patientNames of those within 6 feet of patient


• Asked to obtain travel historyAsked to obtain travel history

If it’s naturally-acquired, where would he If it’s naturally-acquired, where would he have traveled?have traveled?



A.A. AustraliaAustralia

B.B. CanadaCanada

C.C. Western United StatesWestern United States

D.D. Northeast United StatesNortheast United States



C. Western United StatesC. Western United States


• Consulted with public healthConsulted with public health

• All specimens they need have been All specimens they need have been collectedcollected

What treatment regimen would you What treatment regimen would you consider?consider?



A.A. GentamicinGentamicin

B.B. AmpicilinAmpicilin

C.C. TetracyclineTetracycline

D.D. BactrimBactrim





• Plague confirmed by state public healthPlague confirmed by state public health

• Six other suspect casesSix other suspect cases

• Cases clustered in your areaCases clustered in your area

What will public health ask you to do to help What will public health ask you to do to help manage this outbreak?manage this outbreak?



A.A. Close down hospitalClose down hospital

B.B. Call the mediaCall the media

C.C. Conduct chart reviewConduct chart review

D.D. Everyone in building on prophylaxisEveryone in building on prophylaxis



C. Conduct chart reviewC. Conduct chart review


• 12 people in ER12 people in ER

• Compatible symptomsCompatible symptoms

• All attended the hockey gameAll attended the hockey game

What procedure should be in place in the What procedure should be in place in the Emergency Room?Emergency Room?



A.A. All patients into respiratory isolationAll patients into respiratory isolation

B.B. Shut down the ERShut down the ER

C.C. Call public healthCall public health

D.D. A and CA and C



D.D. A and CA and C– All symptomatic patients into isolationAll symptomatic patients into isolation– Call public healthCall public health


• 1,459 confirmed, probable and suspect1,459 confirmed, probable and suspect• Pneumonic plaguePneumonic plague• Associated with ice hockey gameAssociated with ice hockey game• Your hospital has 200 casesYour hospital has 200 cases• Mass Casualty Treatment ProtocolMass Casualty Treatment Protocol

What is one of the medications you will use What is one of the medications you will use for your adult patients?for your adult patients?



A.A. Gentamicin – 5mg/kg IM or IVGentamicin – 5mg/kg IM or IV

B.B. Doxycycline – 100mg PO BIDDoxycycline – 100mg PO BID

C.C. Doxycycline – 100mg IV BID or 200mg Doxycycline – 100mg IV BID or 200mg IVIV

D.D. Ciprofloxacin – 400mg IV BIDCiprofloxacin – 400mg IV BID



B. Doxycycline – 100mg PO BIDB. Doxycycline – 100mg PO BID

Questions for LaboratoriansQuestions for Laboratorians

Plague Scenario LaboratoryPlague Scenario LaboratoryQuestion 1Question 1

• Microbiologist at hospital in Hartford, Microbiologist at hospital in Hartford, ConnecticutConnecticut

• Specimens – pharyngeal swabs, sputum, Specimens – pharyngeal swabs, sputum, serologyserology

• Patient – presenting with pneumoniaPatient – presenting with pneumonia

What presentation would you expect on a What presentation would you expect on a Gram stain if this was plague?Gram stain if this was plague?



A.A. Gram-positive bacillus, singly and chainsGram-positive bacillus, singly and chainsB.B. Faintly staining, very tiny Gram-negative Faintly staining, very tiny Gram-negative

coccobacillus, mostly single cellscoccobacillus, mostly single cellsC.C. Plump, Gram-negative rodPlump, Gram-negative rodD.D. Faintly staining, small Gram-negative Faintly staining, small Gram-negative

coccobacillus, “fine sand”coccobacillus, “fine sand”



C. Plump, Gram-negative rodC. Plump, Gram-negative rod


• Growth plates preparedGrowth plates prepared

• Sheep blood agarSheep blood agar

What presentation would you expect to see What presentation would you expect to see after 48 hours?after 48 hours?


What presentation would you expect to see after 48 What presentation would you expect to see after 48 hours?hours?

A.A. Slow growing, pinpoint, gray-white to opaque Slow growing, pinpoint, gray-white to opaque colonies, “fried egg”colonies, “fried egg”

B.B. Growing poorly, 1-2mm, gray-white, non-hemolyticGrowing poorly, 1-2mm, gray-white, non-hemolyticC.C. Slow growing, pinpoint, smooth, entire border, Slow growing, pinpoint, smooth, entire border,

translucent, non-hemolytictranslucent, non-hemolyticD.D. Rapidly growing, non-pigmented, dry “ground Rapidly growing, non-pigmented, dry “ground

glass” surface, flat or slightly convex, irregular glass” surface, flat or slightly convex, irregular edges with Medusa headedges with Medusa head


What presentation would you expect to see What presentation would you expect to see after 48 hours?after 48 hours?

A.A. Slow growing, pinpoint, gray-white to Slow growing, pinpoint, gray-white to opaque colonies, “fried egg”opaque colonies, “fried egg”


• Suspicious of Suspicious of Y. pestisY. pestis

• Other, more definitive testsOther, more definitive tests

What other characteristics would you expect What other characteristics would you expect to see?to see?



A.A. Hemolysis – None, Catalase (+), Non-Hemolysis – None, Catalase (+), Non-MotileMotile

B.B. Oxidase (-), Catalase (+), Urea (-), Oxidase (-), Catalase (+), Urea (-), Indole (-)Indole (-)

C.C. Oxidase (-), Catalase Weak (+), Oxidase (-), Catalase Weak (+), --lactamase (+), Satellite (-), Urease (-)lactamase (+), Satellite (-), Urease (-)

D.D. Oxidase (+), Urease (+), Satellite (-)Oxidase (+), Urease (+), Satellite (-)



B.B. Oxidase (-), Catalase (+), Urea (-), Oxidase (-), Catalase (+), Urea (-),

Indole (-)Indole (-)

Questions for VeterinariansQuestions for Veterinarians

Plague Scenario VeterinarianPlague Scenario VeterinarianQuestion 1Question 1

• Vet in small-animal practiceVet in small-animal practice• Hartford, ConnecticutHartford, Connecticut• Near ice hockey arenaNear ice hockey arena• Domestic felineDomestic feline• Owner suspects pneumonic plagueOwner suspects pneumonic plague

What signs and symptoms would you expect What signs and symptoms would you expect to see?to see?


What signs and symptoms would you expect to What signs and symptoms would you expect to see?see?

A.A. Fever, respiratory difficulty, excitement and Fever, respiratory difficulty, excitement and depression, vomiting, bloody diarrheadepression, vomiting, bloody diarrhea

B.B. Depression, lymphadenopathy, abcesses, Depression, lymphadenopathy, abcesses, oral or lingual ulceration, anorexiaoral or lingual ulceration, anorexia

C.C. Rapidly progressing illness, fever, cough Rapidly progressing illness, fever, cough bloody sputumbloody sputum


What signs and symptoms would you expect What signs and symptoms would you expect to see?to see?

C. Rapidly progressing illness, fever, cough C. Rapidly progressing illness, fever, cough bloody sputumbloody sputum


• Domestic felineDomestic feline

• Signs and symptoms seem to match Signs and symptoms seem to match plagueplague

What kind of treatment would you begin on What kind of treatment would you begin on this cat?this cat?




B.B. PenicillinPenicillin

C.C. FluorquinolonesFluorquinolones



A. GentamicinA. Gentamicin


• You suspect plagueYou suspect plague

• Lab specimensLab specimens– Pharyngeal swabPharyngeal swab– SerologySerology

• Lab results: Unable to rule out Lab results: Unable to rule out Y. pestisY. pestis




A.A. Send it to private reference laboratorySend it to private reference laboratory

B.B. Call public healthCall public health

C.C. Shut down your practiceShut down your practice



B. Call public healthB. Call public health

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Bioterrorism Agents – Plague Lesson 8 Scenarios and Questions