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51 Cards in this Set
- Front
- Back
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Bioterrorism Definition
Can be _________ or _________ Intentional release can cause (3) Features of a bioweapon include (3) |
Biological agent
- Micro-organisms or toxins Intentional release - Illness - Death - Fear Features of a bioweapon - High morbidity/mortality - Available - Dispersable – air, food, water, mail |
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Bioterrorism
Category A Diseases |
Anthrax (Bacillus anthracis)
Smallpox (Variola virus) Plague (Yersinia pestis) Tularemia (Francisella tularensis) Botulism (botulinum toxin) Viral Hemorrhagic Fever |
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Bacillus anthracis
Anthrax Gram? Rod? cocci? Metabolsim? Capsule? Spores? - Infectious? - Size? |
Gram positive bacillus, “jointed bamboo rod”
Aerobic, encapsulated - Spore-former Size 1μm Inert, infectious form Hardy |
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Bacillus anthracis
Epidemiology Found mostly where? |
Zoonotic disease
- Herbivores - Spores in soil worldwide Human disease - U.S. - 235 cases 1955-94 - 18 inhalational 1900-76 - “Woolsorters Disease” |
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Bioterrorism Potential: Anthrax
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Russia plant malfunction
Mail transmitted in US |
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Anthrax
Disease forms - Determined by spore exposure - _________ - Most common form - Case fatality rate <10% - __________ -Case fatality rate 50% - ___________ - Suspect bioterrorism - Case fatality rate 45-95% |
Disease forms
- Determined by spore exposure - Cutaneous - Most common form - Case fatality rate <10% - Gastrointestinal -Case fatality rate 50% - Inhalational - Suspect bioterrorism - Case fatality rate 45-95% |
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Anthrax skin lesions:
Pain? Showing progression of the lesion from _______ to______ to _____ to eschar |
Painless that heal without a scar (most due to edema not inflammation)
Showing progression of the lesion from papule to bulla to ulcer to eschar Progression of lesion Papule/macule – pruritic Vesicle/bulla – clear or serosanguinous Ulcer – nonpitting gelatinous edema Eschar – black, depressed, rarely scars, where it gets name anthrakis (coal) |
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Anthrax
Inhalational - Incubation __-__ days (range __-__) - Prodromal phase - _______-like illness - _______,_______ (100%) - _______ (90%) - _______, ____<--bold) (80%) - Rhinorrhea <--bold) (10%) - Duration several hours to 3 days Bold = not found in influenza, these are distinguishing features |
Inhalational
- Incubation 1-7 days (range 1-43) - Prodromal phase - Influenza-like illness - Fever/chills, malaise (100%) - Dry cough (90%) - Dyspnea, N/V (80%) - Rhinorrhea (10%) - Duration several hours to 3 days |
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CXR - Anthrax
Does NOT cause airspace _______ _________ mediastinume…The ______ sign. May start somewhat subtle… |
infiltrates
Widened mediastinume…The beeper sign. May start somewhat subtle… (EXAM!) |
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Anthrax Diagnosis:
Inhalational - Diagnosis – _____ ________ - Fulminant phase; leads to ______ - Manifestations (5) - Death <___ hours |
Inhalational
- Diagnosis – blood culture - Fulminant phase – sepsis - Fever, resp. failure, shock, Disseminated intravascular coagulation (DIC), meningitis - Death <36 hours |
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Anthrax Treatment
________ ASAP - Ciprofloxacin or doxycycline Plus 1-2 others (why?) - ___________ ineffective - Duration – ___ days +/- vaccination? Supportive care +/- steroids Person-to-person transmission? |
Antibiotics ASAP
- Ciprofloxacin or doxycycline Plus 1-2 others (in case it is genetically engineered to be resistant) - Cephalosporins ineffective - Duration – 60 days +/- vaccination Supportive care +/- steroids No person-to-person transmission! - Standard precautions |
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Anthrax Essential Pearls
Onset/Course/severity? ________ mediastinum on chest X-ray Skin lesions? pain? Gram? spores? Diagnosis by? Transmission? Treatment? Empiric therapy? |
Rapidly fatal flu-like illness in previous healthy
Widened mediastinum on chest X-ray Painless black skin ulcer Gram positive bacillus forms infectious spores Diagnosis by blood culture No person-to-person transmission Early treatment essential Empiric therapy – ciprofloxacin Single inhalational case is an emergency Contact Local Health Department ASAP |
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Variola virus - Smallpox
Epidemiology Incubation period __-__ days (_-_) (from exposure to prodrome) Transmission? (unlike anthrax) What marks infectiousness? |
Incubation period 12-14 days (7-17)
Transmission – person to person! Droplets– close contacts Airborne possible Fomites 2º attack rate 25-40% Rash marks infectiousness Case fatality rate 30% |
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Variola virus - Smallpox
Airborne possible: Hospital outbreaks from _______ patients Expected route in BT scenario High infectivity- <__ virions, <__ minutes Severe Acute Reaction(SAR?) for unvaccinated - Onset with ______* - Peaks during ________ Which body fluids are infectious? Rarely can transmit <___ hours before rash when oral lesions first appear >80% US population has/ has no sig immunity? |
Airborne possible: Hospital outbreaks from coughing patients
Expected route in BT scenario High infectivity- <10 virions, <15 minutes Severe Acute Reaction(SAR?) for unvaccinated - Onset with rash* - Peaks during first week of rash All body fluids infectious Rarely can transmit <24 hours before rash when oral lesions first appear >80% US population has no sig immunity |
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Smallpox
Prodromal Stage - Sudden severe ___-like illness - 4 - Duration __-__ days Eruptive Stage (Rash) - Characteristic rash? - __________ determines prognosis |
Prodromal Stage
- Sudden severe flu-like illness - High fever, backache, HA, prostration - Duration 3-5 days Eruptive Stage (Rash) - Characteristic rash - Lesion appearance, distribution, progression - Severity of rash determines prognosis |
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Smallpox Rash:
where does it occur? what does it look like initially? |
Rash appearance
Oral mucosal ulcers Maculopapular initially Vesiculopustular - Deep, tense - Umbilicated Deep-seated in the dermis, thus they are tense. They usually form central indentations or umbilications |
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Smallpox Rash:
_________ pattern In order of appearance and severity: |
Centrifugal pattern: the lesions first appear and are most severe on the head and face, and the extremities, including the palms and soles – which is unusual for many other rash illnesses.
In order of appearance and severity - Head, face prominent - Extremities including palms/soles - Trunk relatively spared |
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Smallpox Rash stages:
All of the lesions are ________, meaning that in any one area, all lesions are in the same stage of development. It starts with _________ (or raised bumps), then progresses to the characteristic ________ that turn into _________ that then dry to scabs that eventually fall off and leave _______ ________. |
All of the lesions are synchronous, meaning that in any one area, all lesions are in the same stage of development.
It starts with maculopapular (or raised bumps), then progresses to the characteristic deep seated umbilicated, tense vesicles that turn into pustules that then dry to scabs that eventually fall off and leave permanent scarring. |
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Smallpox: Diagnosis
The main disease that is likely to be confused for smallpox is _________. Normally chickenpox, caused by varicella virus, has a more _______ onset of rash, the lesioins are more ______, ________ , and has a more _________ distribution, affecting the trunk to a greater degree than the distal extremities. It usually spares the _____ and _____. |
The main disease that is likely to be confused for smallpox is chickenpox.
Normally chickenpox, caused by varicella virus, has a more sudden onset of rash, the lesioins are more shallow, asynchronous, and has a more centripetal distribution, affecting the trunk to a greater degree than the distal extremities. It usually spares the palms and soles. |
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Treatment Smallpox
Once symptoms start, __________ only _______ __________ - Protective first 3-4 days after exposure - Reduces incidence 2-3 fold - Decreases mortality by half ____________ - 3 fold decrease in incidence and mortality - Passive immunity for 2 weeks - Very limited supply |
Once symptoms start, supportive only
Smallpox vaccine - Protective first 3-4 days after exposure - Reduces incidence 2-3 fold - Decreases mortality by half Vaccinia immune globulin (VIG) - 3 fold decrease in incidence and mortality - Passive immunity for 2 weeks - Very limited supply |
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Smallpox – Essential Pearls
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Case fatality rate 30%
Clinical diagnosis Prodrome with high fever 3-5 days Eruptive phase with typical rash Centrifugal (head, face, hands/palms, feet/soles) Lesions all same stage of development No specific treatment Human-to-Human transmission Severe chickenpox can look similar Report suspicious cases to Health Dept |
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Yersinia pestis - Plague
Epidemiology Hosts? Transmission vector? Which form is only transmissable person-person? |
Zoonosis
- Rat, prairie dog reservoir - Cats - Flea vector Transmission - Flea bites - Direct contact with infected animals - Person to person – pneumonic form only! - Droplet (natural) or aerosol (BT) |
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Yersinia pestis - Plague
Epidemiology Endemic in American ___ – rodent Fleas feed on infected animal, bacteria form “____” in flea gut, they starve so feed frantically and regurgitate plague bacillus ID50 1-10 organisms Animals include (2)? Must get rid of fleas before rodents or else they jump to humans |
Endemic in American SW – rodent
Fleas feed on infected animal, bacteria form “clot” in flea gut, they starve so feed frantically and regurgitate plague bacillus ID50 1-10 organisms Animals include cats, prairie dogs Must get rid of fleas before rodents or else they jump to humans |
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Plague -
Incubation _-_ days Lesion at _______ (where?) Regional lymph nodes (______) Lungs (________) Sepsis (________) - Acral gangrene - DIC |
Incubation 2-8 days
Lesion at inoculation Regional lymph nodes (Bubonic) Lungs (Pneumonic) Sepsis (Septicemic) - Acral gangrene - DIC |
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Pneumonic Plague
Severe pneumonia: onset? other feature? Diagnosis? Transmission? |
Severe pneumonia
- Rapid onset - Hemoptysis Diagnosis - Sputum culture - Bubo aspirate - Blood culture Person-to-Person Transmission! |
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Plague - Treatment
Which two are first choice drugs? Which is completely ineffective? |
Aminoglycosides (first choice)
- Streptomycin - Gentamicin Doxycycline Chloramphenicol Fluoroquinolones (first choice) - Ciprofloxacin Cephalosporins ineffective |
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Plague Essential Pearls
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Severe pneumonia in previous healthy
Hemoptysis Pneumonia Bipolar staining gram-neg rod in sputum Pneumonic person-to-person transmission Cephalosporins ineffective Aminoglycoside or quinolone 1st choices Report suspect cases ASAP to Health Dept |
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Francisella tularensis - Tularemia
Bug, Gram? Growth? Where does it grow? inside/outside of cell? Geographic distribution? |
Small, pleomorphic Gram neg. coccobacillus
Slow growth - Cysteine media Intracellular Central US |
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Francisella tularensis - Tularemia
Epidemiology Routes of Transmission? (3) Transmission? |
Enzootic across U.S.
- Small mammals (“rabbit fever”) Routes of transmission - Vector - Ticks (Dermacentor) - Deer flies - Contact - Handling infected animals - Ingestion |
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Tularemia: The Disease – General
Incubation __-__d ( range: _-__d) Symptoms? ___ - _____ dissociation ______ at inoculation _______ __________ |
Incubation 3-5d (1-14d)
F/C, low back myalgias Pulse-temp dissociation Ulcer at inoculation Proximal lymphadenopathy |
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The Disease - Pneumonic Tularemia
Pneumonic (symptoms?) |
Pneumonic
- Mod-severe - Non-productive cough - Pleuritic CP - Effusions - 30-60% case fatality |
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Tularemia Essential Pearls
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Rapid onset flu-like illness
Pulse/temperature dissociation Cultures no growth on standard media Alert Micro Lab – dangerous to handle Doesn’t respond to typical antibiotics Report suspect cases to local Health Dept |
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BT Preparedness for Physicians
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Have a high level of suspicion
Keep BT agents in differential diagnosis Serious or unusual infections in o/w healthy Recognize typical BT disease syndromes Know which diseases are contagious Know initial Rx of Category A diseases Know how to report suspected BT Infectious Diseases consult, Health Department |
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Zoonoses
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Infectious with an animal reservoir
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Zoonoses - General Principles
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Large variety (>200 diseases)
Non-human vertebrate reservoir Diagnosis often difficult – serologies Treatment often unique Transmission modes - Direct contact – bites, skin - Indirect contact - aerosol - Ingestion – contaminated food/water - Arthropod intermediate |
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Animal Bite Wounds
Describe approach? |
Assess rabies risk
General care - Irrigate, no sutures - Tetanus booster Assess infection risk - Location - Depth - Animal type (cats > dogs) |
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Rabies
Distribution? Animal reservoirs? Control? |
Epidemiology
- Worldwide distribution - 30K-70K deaths - Animal reservoirs - Wild animals (developed) - Bats, skunks, raccoons, foxes - Dogs (developing) - Bites (saliva), transplant - 100% case-fatality rate* Control - Animal vaccination |
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Rabies
_________ inclusions Must immunize before __________ Brain path? |
Intracytoplasmic inclusions
Must immunize before reaching cord Brain path unclear |
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Rabies Pathogenesis
Family? Genus? genome? Pathogenesis How does it invade, where does it replicate, and how does it spread? |
Rhabdovirus family
Lyssavirus genus - ssRNA, 5 structural proteins Pathogenesis Local replication Retrograde axonal spread - 5-10 cm/day Spinal cord - replicate Dorsal root ganglia Brainstem, thalamus Negri bodies |
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Rabies
Incubation depends on? Non-neuro findings? |
Incubation depends on inoculation site proximity to brain (hope you get bit in the leg)
Non-neuro findings – myocarditis, arrythmias |
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Rabies
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Risk assessment after animal exposure
Animal species & behaviour High risk Bats – any potential bite, presence when not conscious Wild mammals with unusual behaviour – bites Necropsy by health department Low threshold for post-exposure prophylaxis Lower risk Domestic cat, dog Observe animal 10 days Non-mammals no risk |
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Bartonellosis–Cat Scratch Disease
Gram? Intra/extra cellular? populations affected? reservoir? |
Bartonella henselae
Gram negative bacillus Intracellular Epidemiology Mostly kids ~25,000 cases/year Cat reservoir Young outdoor males Scratch or bite |
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Bartonellosis-Cat Scratch Disease
Clinical Features ? Diagnosis - (3)? Treatment: (1) |
Clinical Features
Vesicle/papule/pustule Painful lymphadenitis Fever Encephalopathy Diagnosis - clinical PCR tissue, serology Treatment Azithromycin |
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Q fever
Organism? Direct contact from? Acute? Rx for acute? Chronic? Rx for chronic? Diagnosis? |
Coxiella burnetii
Direct/product contact - Cattle, sheep, goats - Inhalation Acute Flu-like illness Atypical pneumonia Rx - Doxycycline Chronic Endocarditis, osteomyelitis Rx – Doxy + Rifampin Diagnosis - serology |
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Brucellosis
boring crap.... goddamit... |
Brucella melitensis, B. abortus
Intracellular gram negative coccobacillus Sheep, goats, cattle Epidemiology U.S. 100 cases/year Southern states 80% Hispanic origin Transmission Aerosol – placenta Contact (eyes, skin) – urine Ingestion – unpasteurized milk Diagnosis Culture Serology |
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Brucellosis
Clinical? What is unusual in this presentation that does not commonly present in others? Treatment? |
Clinical
Fevers, sweats, malaise, back pain, depression (BOLD <-- unusual presentation) Distinctive – malodorous sweat (BOLD), peculiar taste Bone/joint 20-60%, SI joint, bone scan Acute or chronic, relapse common Systems affected – MSK, GI, GU, cardio, Neuro, skin Treatment 6 weeks doxycycline + aminoglycoside or rifampin |
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Brucellosis
- key clinical features? |
depression
malodorous sweat |
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Leptospirosis
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Leptospira interrogans, others
Gram-negative helical Epidemiology Worldwide – endemic in tropics Sporadic, outbreaks Triathlons Hawaii (128/100,000) Flooding, rainfall Reservoir–dog, rodent Urine Contact |
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Leptospirosis
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Clinical manifestation
90% acute self-limited High fever, HA, myalgias Conjunctival suffusion 30-40% Muscle tenderness (calf, lumbar) 10% biphasic, severe (Weil’s disease) Icterus Renal failure – rapid oliguria Hepatic failure – high CPK 5-40% case-fatality rate Diagnosis – culture, serology Treatment Oral doxycycline IV penicillin – Jarisch-Herxheimer reaction |
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Psittacosis (Ornithosis)
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Chlamydia psittaci
Epidemiology Widespread Very common in birds (pets) 5-8% prevalence Sporadic, occasional outbreaks Transmission Bird contact/presence - discharge, urine, feces Aerosols |
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Psittacosis
Important clinical finding? Treatment? |
Pneumonia
Lower lobe consolidation Treat: Doxycycline |
