PLAGUE

OGUNLAJA OLUWADAMILOLA
ML 608
INTRODUCTION
Plague is a deadly infectious disease that is caused by
the enterobacteria Yersinia pestis, named after the
French-Swiss bacteriologist Alexandre Yersin.
Other names have been used to describe this disease,
such as "The Black Plague" and "The Black Death"
The epidemiological use of the term "plague" is
currently applied to bacterial infections that cause
buboes, although historically the medical use of the
term "plague" has been applied to pandemic
infections in general
Until June 2007, plague was one of the three
epidemic diseases specifically reportable to the World
Health Organization (the other two being cholera and
yellow fever.

DISTRIBUTION OF INFECTION
Infection and transmission
The Oriental rat flea (Xenopsylla cheopsis) engorged with blood after a
blood meal.
This species of flea is the primary vector for the transmission of Yersinia
pestis ( gram negative)the organism responsible for bubonic plague in most
plague epidemics in Asia, Africa, and South America.
Both male and female fleas feed on blood and can transmit the infection.
Transmission of Y. pestis to an uninfected individual is possible by any of the
following means:
1. droplet contact coughing or sneezing on another person
2. direct physical contact touching an infected person, including sexual
contact
3. indirect contact usually by touching soil contamination or a
contaminated surface
4. airborne transmission if the microorganism can remain in the air for long
periods
5. fecal-oral transmission usually from contaminated food or water sources
6. vector borne transmission carried by insects or other animals

HISTORY OF THE DISEASE
In 1894, two bacteriologists, Alexandre Yersin of
France and Kitasato Shibasabur of Japan,
independently isolated the bacterium in Hong
Kong responsible for the Third Pandemic.
In 1898, the French scientist Paul-Louis Simond
(who had also come to China to battle the Third
Pandemic) established the rat-flea vector that
drives the disease. He had noted that persons
who became ill did not have to be in close contact
with each other to acquire the disease.
Incidence naturally occurring plague
Globally
Approximately 1500 cases/year since 1965
25 countries reported cases
> 50% Eastern, S. Africa, esp. Madagascar
U.S.
390 cases/year reported 1947-96
Southwest region of U.S. endemic

PATHOGENESIS
Y. pestis bacillican resist phagocytosis and even reproduce inside
phagocytes and kill them. As the disease progresses, the lymph nodes
can haemorrhage and become swollen and necrotic. Bubonic plague
can progress to lethal septicemic plague in some cases. The plague is
also known to spread to the lungs and become the disease known as
the pneumonic plague. This form of the disease is highly
communicable as the bacteria can be transmitted in droplets emitted
when coughing or sneezing
PERCULARITIES OF YERSINIA PESTIS;
Environmental Survival
Requires host (can not survive in environment well)
Can live weeks in water, grains, moist soil
Lives months/years at just above freezing temperature.Lives only 15 minutes
in 55 C
Lives in dry sputum, corpses, flea feces
Inactivated by sunlight in a few hours
Highly virulent and invasive


Four routes human disease
Flea-bite (most common)
Handling infected animals- skin contact, scratch, bite
Inhalation from humans or animals
Ingesting infected meat
Intracellular organism
Survives in monocytes/macrophages
Inhalation (pneumonic form)
Deposition into alveoli
Classic lobular pneumonia
Resulting manifestation
liquefaction necrosis, residual scarring
FORMS OF PLAGUE
The symptoms of plague depend on the concentrated areas of
infection in each person: bubonic plague in lymph nodes,
septicemic plague in blood vessels, pneumonic plague in lungs.

Clinically there are 5 forms:
1. Bubonic plague
2. Septicemic plague
3. Pneumonic plague
4. Pharyngeal plague
5. Meningeal plague
Other clinical forms
There are a few other rare manifestations of plague, including
asymptomatic plague and abortive plague. Cellulocutaneous
plague sometimes results in infection of the skin and soft tissue,
often around the bite site of a flea.


BUBONIC PLAGUE
MODE OF TRANSMISSION
From contact with infectious material
Usually from bite of infectious flea
Contact with or ingestion of infected animals
CLINICAL FEATURES
The bubonic plague is often the first of a progressive series of illnesses. Bubonic
plague symptoms appear suddenly, usually 25 or 7-10 days after exposure to the
bacteria
Buboes(Lymphadenitis)
Enlarged tender lymph nodes
Usually unilateral
Usually inguinal/femoral in adults
Cervical/submaxillary more common in age < 10
After being transmitted via the bite of an infected flea, the Y. pestis bacteria
become localized in an inflamed lymph node, where they begin to colonize and
reproduce.
Buboes associated with the bubonic plague are commonly found in the armpits,
upper femoral, groin and neck region.
Acral gangrene (i.e., of the fingers, toes, lips and nose) is another common symptom


Other symptoms include:
1. Gangrene of the extremities such as toes, fingers, lips and tip of the
nose.
2. Chills
3. General ill feeling (malaise)
4. High fever (39 C; 102 F)
5. Muscle cramps
6. Seizures
7. Smooth, painful lymph gland swelling called a bubo, commonly found in
the groin, but may occur in the armpits or neck, most often at the site
of the initial infection (bite or scratch)
8. Pain may occur in the area before the swelling appears
9. Skin color changes to a pink hue in some very extreme cases
Other symptoms include heavy breathing, continuous vomiting of blood
(hematemesis), aching limbs, coughing, and extreme pain. The pain is
usually caused by the decay or decomposition of the skin while the person is
still alive.
Additional symptoms include extreme fatigue, gastrointestinal problems,
lenticulae (black dots scattered throughout the body), delirium, and coma

PNEUMONIC PLAGUE
A severe type of lung infection, is one of three
main forms of plague, all of which are caused by
the bacterium Yersinia pestis.
Pneumonic plague is highly contagious and can
quickly spread from person to person.
It is more virulent and rare than bubonic plague
Typically, pneumonic form is due to a spread from
infection of an initial bubonic form.
Untreated pneumonic plague has a very high
fatality rate
MODE OF TRANSMISSION
Pneumonic plague can be caused in two ways:
1. Primary, which results from the inhalation of
aerosolised plague bacteria
2. Secondary, when septicaemic plague spreads into
lung tissue from the bloodstream.
Pneumonic plague is not exclusively vector-borne like
bubonic plague; instead it can be spread from person
to person without involvement of fleas or rats.
There have been cases of pneumonic plague resulting
from the dissection or handling of contaminated
animal tissue. This is one type of the formerly known
Black Death
CLINICAL PICTURE
In pneumonic plague, the first signs of illness are fever, headache, weakness and
rapidly developing pneumonia with shortness of breath, chest pain, cough and
sometimes bloody or watery sputum.
The most apparent symptom of pneumonic plague is coughing, often with
hemoptysis (coughing up blood).
The pneumonia progresses for two to four days and may cause respiratory
failure and shock. Patients will die without early treatment, some within 36
hours.
Initial pneumonic plague symptoms can often include the following:
Fever
Weakness
Headaches
Nausea
Rapidly developing pneumonia with:
Shortness of breath
Chest pain
Cough
Bloody or watery sputum (saliva and discharge from respiratory passages).

SEPTICEMIC PLAGUE
It is the rarest form of 3 main forms of plague.
Septicemic plague can cause disseminated
intravascular coagulation, and is almost always
fatal when untreated.
Septicemic plague occurs when bubonic
plague leads to an infection of the blood.
MODE OF TRANSMISSION
Septicemic plague is caused by horizontal and direct transmission.
1. Horizontal transmission is the transmitting of a disease from one
individual to another regardless of blood relation.
2. Direct transmission occurs from close physical contact with
individuals, through common air usage, from direct bite from a flea or
an infected rodent. Most common rodents may carry the bacteria and
so may Leporidae such as rabbits

If the bacteria happen to enter the bloodstream rather than the lymph
or lungs, they multiply in the blood, causing bacteremia and severe sepsis .
In septicemic plague, bacterial endotoxins cause disseminated
intravascular coagulation (DIC), where tiny blood clots form throughout
the body, commonly resulting in localised ischemic necrosis, tissue death
from lack of circulation and perfusion.
DIC results in depletion of the body's clotting resources, so that it can no
longer control bleeding. Consequently, the unclotted blood bleeds into the
skin and other organs, leading to red or black patchy rash and to
hematemesis (vomiting blood) or hemoptysis (spitting blood). The rash
may cause bumps on the skin that look somewhat like insect bites, usually
red, sometimes white in the center.

CLINICAL PICTURE
The usual symptoms in humans are:
1. Abdominal pain
2. Bleeding under skin due to blood clotting problems
3. Bleeding from mouth, nose or rectum
4. Diarrhea
5. Fever
6. Chills
7. Low blood pressure
8. Nausea
9. Organ failure
10. Vomiting
11. Shock
12. Death of tissue (gangrene) causing blackening in extremities, mostly
fingers, toes and nose
13. Difficulty breathing
However, septicemic plague may cause death before any symptoms occur.
Since septicemic plague can be carried by animals, symptoms
you should look for are:
1) Painfully swollen lymph nodes (with possible abscesses)
2) Fever
3) Inflammation
4) Depression
5) Anorexia
6) Vomiting
7) Dehydration
8) Diarrhea
9) Enlarged tonsils
10) Discharge from eyes
11) Loss of appetite/Visible weight loss
12) Mouth ulcers
13) Systemic infection of the blood
14) Coma may follow

DIAGNOSIS
1. Microscopy
Gram staining or Giemsa- we see bipolar stained rods
Direct Immunofluorescence; rapid- immediate
identification and presence of yersinia pestis F1
antigen(capsule)
2. Culture samples of body fluids
Grows well on most non-selective standard
media(27degrees). Although cultures are highly infectious
and must be handled carefully.
3. Serological tests- Hemagglutination inhibition is seem
4. Rapid dipstick test
5. Biopsy of lymphnodes
TREATMENT
For Bubonic form , aminoglycosides such as streptomycin and
gentamicin, tetracyclines (especially doxycycline), and the fluoroquinolone
ciprofloxacin.
Using the broad-based antibiotic streptomycin has proven to be
dramatically successful against the bubonic plague within 12 hours of
infection
Mortality associated with treated cases of bubonic plague is about 115%,
compared to a mortality of 4060% in untreated cases
For Pneumonic form, which is a very aggressive infection requiring
early treatment. Antibiotics must be given within 24 hours of first symptoms
to reduce the risk of death. Streptomycin, gentamicin, tetracyclines and
chloramphenicol are all effective.
Antibiotic treatment for 7 days will protect people who have had direct,
close contact with infected patients. Wearing a close-fitting surgical mask
also protects against infection.
The mortality rate from untreated pneumonic plague approaches 100%

For Septicemic form:
One of the following antibiotics may
beused:Streptomycin,Gentamicin,Tetracyline or
doxycycline,Chloramphenicol,Ciprofloxacin
1) Lymph nodes may require draining and the
patient will need close monitoring.
2) Intravenous drip may be used to assist in
dehydration scenarios.
3) Flea treatment can also be used.
4) In some cases euthanasia may be the best
option for treatment and to prevent further
spreading

Immunization
Waldemar Haffkine, a doctor who worked in Bombay, India,
was the first to invent and test a plague vaccine against
bubonic plague in 1897.
Routine vaccination is not needed other than for those at
particularly high risk of exposure, nor for people living in areas
with enzootic plague, such as the western United States.
The CDC thus only recommends vaccination for:
(1) all laboratory and field personnel who are working with
Y. pestis organisms resistant to antimicrobials
(2) people engaged in aerosol experiments with Y. pestis
(3) people engaged in field operations in areas with enzootic
plague where preventing exposure is not possible (such as
some disaster areas

PREVENTION
The following steps can be effective to avoid infection of
plague.
1. Caregivers of infected patients should wear masks,
gloves, goggles and gowns
2. Take antibiotics if close contact with infected patient has
occurred
3. Use insecticides throughout house
4. Avoid contact with dead rodents or sick cats
5. Set traps if mice or rats are present around the house
6. Do not allow family pets to roam in areas where plague
is common
7. Flea control and treatment for animals (especially
rodents)