Plague in the 21st Century: All you need to know!

PlagueThe plague was and is a flea-transmitted infectious bacterial infection. This is a very mundane origin for something that came to be known as the Black Death during the Middle Ages and has inspired such fictional works as Poe’s The Masque of the Red Death and Bergman’s The Seventh Seal. Still, this condition has reached a larger than life – or more appropriately, larger than death –, legendary status. This is due in no small part to the fact that we refer to the Plague as we would refer to Atlantis or El Dorado – fictional but memorable nonetheless. What would make the Plague seem fictional is that it is so antique; it was first mentioned in the Hebrew Bible – notorious for its many instances of imaginary events – and what is known as the ‘modern’ plague occurred between the 1860s and 1890s. Moreover, the personal protection equipment that plague doctors used back in the day consisted of a hat, a beak-shaped mask, and a long gown. But make no mistake; the Plague is very real and very present, if not as deadly as it used to be.

Types and symptoms

Types

Symptoms

Bubonic

·         Chicken egg-sized swollen lymph nodes (buboes) in the groin, armpit, or neck that are tender to the touch.

·         Sudden fever and chills.

·         Headache.

·         Fatigue.

·         Malaise.

·         Muscle aches.

·         Weakness.

Septicemic

·         Fever and chills.

·         Abdominal pain.

·         Diarrhea.

·         Vomiting.

·         Bleeding from mouth, nose or rectum, or under the skin.

·         Gangrene in the fingers, toes, and nose.

·         Extreme weakness.

·         Shock.

Pneumonic

·         Rapidly-developing pneumonia.

·         Chest pain.

·         Cough with bloody sputum.

·         Bloody or watery mucus.

·         Problems breathing.

·         High fever.

·         Nausea.

·         Vomiting.

·         Weakness.

Non-specific

·         Nausea.

·         Vomiting.

·         Diarrhea.

·         Abdominal pain.

 

The plague is caused by a bacterium called Yersinia pestis, which cycles between rats and their fleas in urban areas or other places with high rat populations – like Hamelin, which is by the way another example of a myth-like occurrence with real-life origins. In present time United States of America the plague is most common in semi-arid upland forests and grasslands in western States where rock squirrels, wood rats, ground squirrels, prairie dogs, chipmunks, mice, voles, rabbits and other rodents thrive.

Transmission

·         Flea bites

The prevalent method of transmission takes place when fleas that have previously fed on plague-infected animals bite human beings.

·         Contaminated fluid or tissue

People can also become infected if they come in contact with the tissue or bodily fluids of infected animals.

·         Infectious droplets

This is the only form of human-to-human transmission, in which droplets coughed up by a person with pneumonic plague are breathed in by another person. Additionally, cats that have eaten infected rodents can infect their owners via infectious droplets as well. 

 

In the aforementioned biblical account, the Philistines of Ashdod were stricken with a plague for stealing the Ark of the Covenant – at least they got off easier than the Nazis in Raiders of the Lost Ark. Today, the risk of becoming infected with the Plague is rather low, but by no means non-existent.

Risk factors

·         Location

People who live in or visit places where there have been die-offs or plague epizootics (periods during which a significant proportion of a population dies naturally within a short span) of rodents are at an increased risk of flea bites, because hungry fleas start looking for alternate sources of blood.

·         Occupation

Veterinarians are at a higher risk of contracting the Plague from infected domestic cats as mentioned above.

·         Other

Activities such as hunting or hiking are also risk factors. In the former, skinning rabbits and other infected animals can result in bubonic or septicemic plague. In the latter, the risk of flea bite exposure can increase when hiking in areas where infected animals inhabit.

 

Buboes are often the earliest signs of the bubonic form of this condition (also the most common). Accordingly, a bubo plus a flea bite can lead a doctor to put two and two together and suspect the Plague – especially in a person who shows the symptoms and lives in or has recently traveled to the western United States. This suspicion may be confirmed with a fluid sample from the swollen lymph node. Additionally, Yersinia pestis can also be detected through blood or sputum samples in cases of septicemic or pneumonic plague, respectively.

Testing and diagnosis

·         Lymph node aspirate

Infected buboes should contain multiple organisms that can be evaluated via microscope or by culture.

·         Blood culture

Blood smears may show organisms in septicemic patients. Conversely, blood smears from bubonic patients are often negative for bacteria by microscopic examination early in the course of disease.

·         Sputum culture

It is possible in very ill pneumonic patients.

·         Bronchial/tracheal washing

May be taken from suspected pneumonic patients. However, throat specimens are not ideal because they may contain many other bacteria.

·         Gram, Wright, Giemsa, or Wayson's stained smears/peripheral blood, sputum/lymph node specimen

Yersinia pestis can be found by microscopic examination. Visualization of bipolar-staining, ovoid, Gram-negative organisms with a "safety pin" appearance allows for a quick presumptive diagnosis of plague.

 

In the case of unculturable live organisms, lymphoid, spleen, lung, and liver tissue or bone marrow samples may offer evidence of infection by direct detection methods like direct fluorescent antibody (DFA) or PCR. If the Plague is suspected even if cultures provide negative results, a serum specimen taken as early as possible – with a convalescent sample following 4 to 6 weeks after the onset of disease – can confirm or deny the diagnosis. Once the Plague has been diagnosed, what follows is isolation in a hospital room and a course of strong antibiotics.

Plague treatment

 

Preferred antibiotics

Dose

Administration

 

 

 

 

Adults

Streptomycin

1 g two times a day

IM

Gentamicin

5 mg/kg once a day, or 2 mg/kg loading dose followed by 1.7 mg/kg every 8 hours

IM or IV

Alternative antibiotics

 

 

Doxycycline

100 mg two times a day or 200 mg once a day

IV

Ciprofloxacin

400 mg twice daily

Chloramphenicol

25 mg/kg  every 6 hours

 

 

 

 

 

 

 

Children

Preferred antibiotics

 

 

Streptomycin

15 mg/kg twice daily (max. daily dose, 2 g)

IV

Gentamicin

2.5 mg/kg every 8 hours

IM or IV

Alternative antibiotics

 

 

Doxycycline (for children ≥ 8 years)

Weight < 45 kg: 2.2 mg/kg twice daily (max. daily dose, 200 mg)
Weight ≥ 45 kg: same as adult dose

IV

Ciprofloxacin

15 mg/kg twice daily (max. daily dose, 1 g)

Chloramphenicol (for children > 2 years)

25 mg/kg every 6 h (max. daily dose, 4 g)

 

 

Pregnant women

Preferred antibiotics

 

 

Gentamicin

Same as adult dose

IM or IV

Alternative antibiotics

 

 

Doxycycline

Same as adult dose

IV

Ciprofloxacin

 

Ideally, there is absolutely no reason why anybody should succumb to this disease anymore. But that doesn’t mean either that you can simply walk it off or tough it out – if not treated as soon as possible, the Plague can still go medieval on you. For instance, untreated bubonic plague can invade the bloodstream and cause septicemic plague as well as secondary pneumonic plague if the lungs are seeded – thus hitting the trifecta. As it is usually the case, prevention is ever the best medicine.

Preventing the Plague

·         Rodent-proofing

Remove piles of brush, rock, firewood, junk, and other potential nesting areas, as well as possible rodent food supplies like pert and wild animal food from your home.

·         The only good Flea is RHCP’s bassist

Use flea control products on your pets. Don’t let your dog or cat roam freely in plague-endemic areas – and if they do, don’t let them sleep on your bed. Take sick pets to the veterinarian immediately.

·         Repellent

Apply DEET-containing insect repellent on children, pets, and yourself when outside in areas with large populations of rodents.

·         Other

Wear gloves when handling or skinning animals that might be infected.

 

The plague was and is a flea-transmitted infectious bacterial infection. This is a very mundane origin for something that came to be known as the Black Death during the Middle Ages and has inspired such fictional works as Poe’s The Masque of the Red Death and Bergman’s The Seventh Seal. Still, this condition has reached a larger than life – or more appropriately, larger than death –, legendary status. This is due in no small part to the fact that we refer to the Plague as we would refer to Atlantis or El Dorado – fictional but memorable nonetheless. What would make the Plague seem fictional is that it is so antique; it was first mentioned in the Hebrew Bible – notorious for its many instances of imaginary events – and what is known as the ‘modern’ plague occurred between the 1860s and 1890s. Moreover, the personal protection equipment that plague doctors used back in the day consisted of a hat, a beak-shaped mask, and a long gown. But make no mistake; the Plague is very real and very present, if not as deadly as it used to be.

Types and symptoms

Types

Symptoms

Bubonic

·         Chicken egg-sized swollen lymph nodes (buboes) in the groin, armpit, or neck that are tender to the touch.

·         Sudden fever and chills.

·         Headache.

·         Fatigue.

·         Malaise.

·         Muscle aches.

·         Weakness.

Septicemic

·         Fever and chills.

·         Abdominal pain.

·         Diarrhea.

·         Vomiting.

·         Bleeding from mouth, nose or rectum, or under the skin.

·         Gangrene in the fingers, toes, and nose.

·         Extreme weakness.

·         Shock.

Pneumonic

·         Rapidly-developing pneumonia.

·         Chest pain.

·         Cough with bloody sputum.

·         Bloody or watery mucus.

·         Problems breathing.

·         High fever.

·         Nausea.

·         Vomiting.

·         Weakness.

Non-specific

·         Nausea.

·         Vomiting.

·         Diarrhea.

·         Abdominal pain.

 

The plague is caused by a bacterium called Yersinia pestis, which cycles between rats and their fleas in urban areas or other places with high rat populations – like Hamelin, which is by the way another example of a myth-like occurrence with real-life origins. In present time United States of America the plague is most common in semi-arid upland forests and grasslands in western States where rock squirrels, wood rats, ground squirrels, prairie dogs, chipmunks, mice, voles, rabbits and other rodents thrive.

Transmission

·         Flea bites

The prevalent method of transmission takes place when fleas that have previously fed on plague-infected animals bite human beings.

·         Contaminated fluid or tissue

People can also become infected if they come in contact with the tissue or bodily fluids of infected animals.

·         Infectious droplets

This is the only form of human-to-human transmission, in which droplets coughed up by a person with pneumonic plague are breathed in by another person. Additionally, cats that have eaten infected rodents can infect their owners via infectious droplets as well. 

 

In the aforementioned biblical account, the Philistines of Ashdod were stricken with a plague for stealing the Ark of the Covenant – at least they got off easier than the Nazis in Raiders of the Lost Ark. Today, the risk of becoming infected with the Plague is rather low, but by no means non-existent.

Risk factors

·         Location

People who live in or visit places where there have been die-offs or plague epizootics (periods during which a significant proportion of a population dies naturally within a short span) of rodents are at an increased risk of flea bites, because hungry fleas start looking for alternate sources of blood.

·         Occupation

Veterinarians are at a higher risk of contracting the Plague from infected domestic cats as mentioned above.

·         Other

Activities such as hunting or hiking are also risk factors. In the former, skinning rabbits and other infected animals can result in bubonic or septicemic plague. In the latter, the risk of flea bite exposure can increase when hiking in areas where infected animals inhabit.

 

Buboes are often the earliest signs of the bubonic form of this condition (also the most common). Accordingly, a bubo plus a flea bite can lead a doctor to put two and two together and suspect the Plague – especially in a person who shows the symptoms and lives in or has recently traveled to the western United States. This suspicion may be confirmed with a fluid sample from the swollen lymph node. Additionally, Yersinia pestis can also be detected through blood or sputum samples in cases of septicemic or pneumonic plague, respectively.

Testing and diagnosis

·         Lymph node aspirate

Infected buboes should contain multiple organisms that can be evaluated via microscope or by culture.

·         Blood culture

Blood smears may show organisms in septicemic patients. Conversely, blood smears from bubonic patients are often negative for bacteria by microscopic examination early in the course of disease.

·         Sputum culture

It is possible in very ill pneumonic patients.

·         Bronchial/tracheal washing

May be taken from suspected pneumonic patients. However, throat specimens are not ideal because they may contain many other bacteria.

·         Gram, Wright, Giemsa, or Wayson's stained smears/peripheral blood, sputum/lymph node specimen

Yersinia pestis can be found by microscopic examination. Visualization of bipolar-staining, ovoid, Gram-negative organisms with a "safety pin" appearance allows for a quick presumptive diagnosis of plague.

 

In the case of unculturable live organisms, lymphoid, spleen, lung, and liver tissue or bone marrow samples may offer evidence of infection by direct detection methods like direct fluorescent antibody (DFA) or PCR. If the Plague is suspected even if cultures provide negative results, a serum specimen taken as early as possible – with a convalescent sample following 4 to 6 weeks after the onset of disease – can confirm or deny the diagnosis. Once the Plague has been diagnosed, what follows is isolation in a hospital room and a course of strong antibiotics.

Plague treatment

 

Preferred antibiotics

Dose

Administration

 

 

 

 

Adults

Streptomycin

1 g two times a day

IM

Gentamicin

5 mg/kg once a day, or 2 mg/kg loading dose followed by 1.7 mg/kg every 8 hours

IM or IV

Alternative antibiotics

 

 

Doxycycline

100 mg two times a day or 200 mg once a day

IV

Ciprofloxacin

400 mg twice daily

Chloramphenicol

25 mg/kg  every 6 hours

 

 

 

 

 

 

 

Children

Preferred antibiotics

 

 

Streptomycin

15 mg/kg twice daily (max. daily dose, 2 g)

IV

Gentamicin

2.5 mg/kg every 8 hours

IM or IV

Alternative antibiotics

 

 

Doxycycline (for children ≥ 8 years)

Weight < 45 kg: 2.2 mg/kg twice daily (max. daily dose, 200 mg)
Weight ≥ 45 kg: same as adult dose

IV

Ciprofloxacin

15 mg/kg twice daily (max. daily dose, 1 g)

Chloramphenicol (for children > 2 years)

25 mg/kg every 6 h (max. daily dose, 4 g)

 

 

Pregnant women

Preferred antibiotics

 

 

Gentamicin

Same as adult dose

IM or IV

Alternative antibiotics

 

 

Doxycycline

Same as adult dose

IV

Ciprofloxacin

 

Ideally, there is absolutely no reason why anybody should succumb to this disease anymore. But that doesn’t mean either that you can simply walk it off or tough it out – if not treated as soon as possible, the Plague can still go medieval on you. For instance, untreated bubonic plague can invade the bloodstream and cause septicemic plague as well as secondary pneumonic plague if the lungs are seeded – thus hitting the trifecta. As it is usually the case, prevention is ever the best medicine.

Preventing the Plague

·         Rodent-proofing

Remove piles of brush, rock, firewood, junk, and other potential nesting areas, as well as possible rodent food supplies like pert and wild animal food from your home.

·         The only good Flea is RHCP’s bassist

Use flea control products on your pets. Don’t let your dog or cat roam freely in plague-endemic areas – and if they do, don’t let them sleep on your bed. Take sick pets to the veterinarian immediately.

·         Repellent

Apply DEET-containing insect repellent on children, pets, and yourself when outside in areas with large populations of rodents.

·         Other

Wear gloves when handling or skinning animals that might be infected.