# Presentation: 403348

## Bioterrorism Agents – PlagueLesson 8

- Scenarios and Questions

## Overview

- Developing scenario
- Questions to review knowledge
- Additional questions for laboratorians and veterinarians

**Notes:**
In this section, we will provide you with a developing scenario and several questions to help you ascertain your knowledge of the material.

## Plague Scenario Question 1

- Physician in Hartford, Connecticut
- 35yo male, no underlying
- Fever, chills, malaise, myalgias x 3 days
- Productive cough, watery mucoid sputum, chest pain x 1 day
- What would you review to rule out other diseases?

**Notes:**
Scenario:  You are a physician in a hospital in Hartford, Connecticut.

  35 year old, male patient.  No underlying medical conditions. 
  Fever, chills, malaise and myalgias time three days.
  Onset yesterday productive cough with watery mucoid sputum and some chest pain.
What kinds of signs, symptoms and clues would you review to help you rule out other diseases? (Check all that apply.)

## Plague Scenario Question 1

- What would you review to rule out other diseases?
- Mediastinum on x-ray
- Progression of disease
- Presence of influenza
- A and C
- A, B and C

**Notes:**
A.  Review of mediastinum on x-ray
Progression of disease
C.  Presence of influenza in community
D.  A and C
E.  A, B and C

## Plague Scenario Question 1

- What would you review to rule out other diseases?
- A, B and C
- Mediastinum on x-ray
- Progression of disease
- Presence of influenza

**Notes:**
The best answer is E.  All three clues should be reviewed to help rule out other diseases. Reviewing the state of the mediastinum on x-ray is an excellent way to rule out anthrax.  And looking for the presence of influenza in the community can help you figure out if there is a viral cause to the illness.  And looking at the progression of the disease is also important, as other community-acquired pneumonias tend to be less indolent.

## Plague Scenario Question 2

- Patient deteriorating rapidly
- No widening of mediastinum
- No influenza in community
- You suspect plague
- What specimens will you collect for laboratory workup?

**Notes:**
Scenario:  Your patient is deteriorating rapidly.  You have looked at the chest x-ray and observe no widening of the mediastinum.  According to the latest public health agency statistics, there is no influenza in your community.
You suspect plague.  What specimens will you collect for the laboratory workup?

## Plague Scenario Question 2

- What specimens will you collect for laboratory workup?
- Pharyngeal swabs
- Tracheal wash or aspirates
- Sputum specimens
- Serology
- All of the above

**Notes:**
A.  Pharyngeal swabs
B.  Tracheal wash or aspirates
C.  Sputum specimens
D.  Serology
E.  All of the above

## Plague Scenario Question 2

- What specimens will you collect for laboratory workup?
- E.  All of the above
- Pharyngeal swabs
- Tracheal wash or aspirates
- Sputum specimens
- Serology

**Notes:**
The best answer is E, all of the above.  All of these tests would be useful in the diagnosis of pneumonic plague.  Because of the length of time it takes for the test, serology is really only useful for public health, but will be critical to obtain before treatment for the management of the outbreak.

## Plague Scenario Question 3

- Laboratory initial report
- Small, gram-negative, bipolar-staining, plump rods in single, short chains
- Catalase positive
- Oxidase and urease negative
- Unable to rule out *Y. pestis*
- You suspect plague
- What is your next step?

**Notes:**
The laboratory’s initial report indicates small, gram-negative and bipolar-staining, plump rods in singles, short chains that are catalase positive, and oxidase and urease negative.  Your hospitals laboratorian is unable to rule out Y. pestis.  
You are now seriously suspicious of pneumonic plague.  What is your next step?

## Plague Scenario Question 3

- What is your next step?
- Shut down the hospital
- Refer to hospitals reference laboratory
- Call public health
- All of the above

**Notes:**
A.  Shut down the hospital
B.  Instruct the laboratory to send the specimens to your hospital’s regular reference laboratory.
C.  Call the Health Department
D.  All of the above.

## Plague Scenario Question 3

- What is your next step?
- C.  Call public health

**Notes:**
The best answer is C.  Any suspicion of plague should be called in the health department immediately so that appropriate interventions can begin. Patients should also be placed on respiratory precautions until it has been ruled out, or the patient has been on antibiotics for at least three days. 

Anyone suspected of having plague should be placed on respiratory precautions until it has been ruled out or the patient has been on antibiotics for at least three days.  However, if appropriate respiratory precautions are observed, you do not need to quarantine the hospital.  If your sentinel laboratory is unable to rule out Y. pestis, it could signal a public health emergency and should only be handled by the public health laboratory.  

## Plague Scenario Question 4

- You’ve contacted your hospitals infection control practitioner
- What should your infection control practitioner recommend to you?

**Notes:**
By the time you were ready to contact public health, you probably already contacted the infection control practitioner in your hospital.
What should your infection control practitioner recommend to you?

## Plague Scenario Question 4

- What should your infection control practitioner recommend to you?
- Patient on respiratory precautions
- Close contacts on prophylaxis
- Names of those within 6 feet of patient
- A and C

**Notes:**
A.  Put the patient on respiratory precautions
B. Begin all close contacts on prophylaxis
C. Get the names of everyone who was within 6 feet of the patient
D.  A and C.

## Plague Scenario Question 4

- What should your infection control practitioner recommend to you?
- A and C
- Patient on respiratory precautions
- Names of those within 6 feet of patient

**Notes:**
The best answer is A and C.  Anyone who was within 6 feet of the patient should be noted so that they may be started on prophylaxis if public health confirms the diagnosis. Anyone suspected of having plague should be placed on respiratory precautions until it has been ruled out or the patient has been on antibiotics for at least three days.

Prophylaxis should not be started unless public health confirms the diagnosis. Anyone who was within 6 feet of the patient should be noted so that they may be started on prophylaxis if public health confirms the diagnosis.

What is Public Health Doing?
When you call public health to report a suspect case of plague, they will advise you on the laboratory testing that needs to be done and any recommended infection control procedures.  They will also ask you to obtain a travel history from the patient and/or his family to help rule out bioterrorism.  
While you are doing this, the nearest LRN laboratory will begin preparing for the arrival of your specimens for confirmatory testing.

## Plague Scenario Question 5

- Asked to obtain travel history
- If it’s naturally-acquired, where would he have traveled?

**Notes:**
You have been asked by the public health agency to determine the patient’s travel history.  
Where would you expect him to say he’s traveled, if this was a naturally-acquired case of plague?

## Plague Scenario Question 5

- If it’s naturally-acquired, where would he have traveled?
- Australia
- Canada
- Western United States
- Northeast United States

**Notes:**
A.  Australia
B.  Canada
The Western United States
D.  The Northeast United States

## Plague Scenario Question 5

- If it’s naturally-acquired, where would he have traveled?
- C.  Western United States

**Notes:**
The best answer is C.  In the United States, plague occurs in the Western states, but mostly in the Southwest.

There have been no documented cases of domestic plague in Australia. Most cases of plague occur in Africa, with limited outbreaks in Asia and South America. Canada has not had cases of plague.  In the United States, we see plague in the Western states.  

What is Public Health Doing?
Public health will be placing staff on standby, pending the results of your testing.  They might send staff to obtain the travel history, instead of having you do it.

## Plague Scenario Question 6

- Consulted with public health
- All specimens they need have been collected
- What treatment regimen would you consider?

**Notes:**
You have consulted with the public health agency and ensured that you have all the specimens they need for laboratory confirmation.
What treatment regimen will you consider for the patient now?

## Plague Scenario Question 6

- What treatment regimen would you consider?
- Gentamicin
- Ampicilin
- Tetracycline
- Bactrim

**Notes:**
A.  Gentamicin
B.  Ampicilin
C.  Tetracycline
D.  Bactrim

## Plague Scenario Question 6

- What treatment regimen would you consider?
- Gentamicin

**Notes:**
The best answer is A, Gentamicin.  Since Streptamicin is so difficult to find in the United States, gentamicin is the recommended treatment at 5 mg/kg IM or IV once daily or 2 mg/kg loading dose followed by 1.7 mg/kg IM or IV three times daily.

While the other antibiotics are possible treatments, gentamicin is preferred.

What is Public Health Doing?
Public health has now activated their reference Laboratory Response Network laboratory to receive the specimens from your sentinel laboratory.

## Plague Scenario Question 7

- Plague confirmed by state public health
- Six other suspect cases
- Cases clustered in your area
- What will public health ask you to do to help manage this outbreak?

**Notes:**
The state’s public health laboratory has confirmed plague.  They also tell you that, in addition to your patient, there are currently six additional suspect cases at other hospitals in the area. 
What will public health ask you to do in order to help them manage this outbreak?

## Plague Scenario Question 7

- What will public health ask you to do to help manage this outbreak?
- Close down hospital
- Call the media
- Conduct chart review
- Everyone in building on prophylaxis

**Notes:**
Close down your hospital to all new patients.
B.  Call the media.
Look for other possible plague cases in your hospital using a chart review
D.   Start anyone who is in the building on prophylaxis. 

## Plague Scenario Question 7

- What will public health ask you to do to help manage this outbreak?
- C.  Conduct chart review

**Notes:**
The best answer is C.  You should look for other patients in your hospital with the same symptoms who might not have been tested for plague.

You should keep your hospital open so that other possible plague patients could seek treatment. You should NOT contact the media unless you coordinate your message with your public health agency, first.  Confusing messages from multiple sources could create panic. The only people who will require prophylaxis are those who were within 6 feet of the patient when he was symptomatic.

What is Public Health Doing?
With the confirmation of your plague case in someone with no known exposure and the addition of six additional cases in your area, public health will be highly suspicious of bioterrorism.
Some of the activities they will do include:
  Looking for a common exposure
  Conducting environmental sampling
  Working with state and federal law enforcement authorities to see if there is anything in their knowledge that indicates bioterrorism

## Plague Scenario Question 8

- 12 people in ER
- Compatible symptoms
- All attended the hockey game
- What procedure should be in place in the Emergency Room?

**Notes:**
The Chief of the ER has been taking part in the chart review and calls you to say that there are currently 12 people in the ER who are presenting with symptoms of pneumonia who are saying that they attended the hockey game.
What procedure should be in place in the ER?

## Plague Scenario Question 8

- What procedure should be in place in the Emergency Room?
- All patients into respiratory isolation
- Shut down the ER
- Call public health
- A and C

**Notes:**
A. All patients with symptoms of pneumonia should be placed in respiratory isolation
B.  The ER should be shut down
C.  Call the public health agency.
D.  A and C.

## Plague Scenario Question 8

- What procedure should be in place in the Emergency Room?
- A and C
- All symptomatic patients into isolation
- Call public health

**Notes:**
The best answer is D.  The most important steps to be taken are to isolate all patients presenting with pneumonia symptoms and to contact your public health agency.

In light of a confirmed case of plague pneumonia and the link to the hockey game, all these patients presenting with pneumonia symptoms should be isolated until plague can be ruled out. There is no need to shut down the ER if plague patients present, as long as those with symptoms are isolated immediately.  Hospitals might wish to establish another entrance for those with pneumonia symptoms to assist in isolation. 

What is Public Health Doing?

  Notifying all healthcare providers in the area to report cases with similar symptomotology
  Activating their emergency response plan with full support staff.
  Creating and coordinating media messages for the public.

## Plague Scenario Question 9

- 1,459 confirmed, probable and suspect
- Pneumonic plague
- Associated with ice hockey game
- Your hospital has 200 cases
- Mass Casualty Treatment Protocol
- What is one of the medications you will use for your adult patients?

**Notes:**
Your public health agency has issued an urgent Health Alert Network (HAN) message indicating that there are currently 1,459 cases of confirmed, probable and suspect pneumonic plague associated with attendance at this ice hockey game.  Your hospital is now up to 200 cases.
The public health agency advises changing to the Mass Casualty Treatment Protocol.
What is one of the medications you will use in this situation for your adult patients?

## Plague Scenario Question 9

- What is one of the medications you will use for your adult patients?
- Gentamicin – 5mg/kg IM or IV
- Doxycycline – 100mg PO BID
- Doxycycline – 100mg IV BID or 200mg IV
- Ciprofloxacin – 400mg IV BID

**Notes:**
Gentamicin - 5 mg/kg IM or IV once daily
B. Doxycycline - 100 mg orally twice daily
C. Doxycycline - 100 mg IV twice daily or 200 mg IV once daily
D. Ciprofloxacin - 400 mg IV twice daily

## Plague Scenario Question 9

- What is one of the medications you will use for your adult patients?
- B.  Doxycycline – 100mg PO BID

**Notes:**
The best answer is B.  Doxycycline given orally is one of the preferred medications to use in mass casualty situations, since clinical staff will be unable to take the time to place IV medications with so many patients.

Gentamicin IM or IV, Doxycycline IV, and Ciprofloxacin IV are best used in contained casualty situations.

What is Public Health Doing?

Activities are now in full response mode.  
  Conducting environmental testing both at the ice hockey arena and all around the affected area.  
  Interviewing all the cases to try to learn more about the exposure and anyone else who might need assistance.
  Deploying the Strategic National Stockpile.  Community prophylaxis clinics could be recommended.
  Working with the veterinary community to monitor disease in animals so that disease spread can be limited through that means, as well.

## Questions for Laboratorians

## Plague Scenario LaboratoryQuestion 1

- Microbiologist at hospital in Hartford, Connecticut
- Specimens – pharyngeal swabs, sputum, serology
- Patient – presenting with pneumonia
- What presentation would you expect on a Gram stain if this was plague?

**Notes:**
You are the microbiologist at the hospital in Hartford, Connecticut.  A doctor has just submitted pharyngeal swabs, a sputum sample and a serology on a patient presenting with pneumonia.
What presentation would you expect on a Gram stain if this was plague?

## Plague Scenario LaboratoryQuestion 1

- What presentation would you expect on a Gram stain if this was plague?
- Gram-positive bacillus, singly and chains
- Faintly staining, very tiny Gram-negative coccobacillus, mostly single cells
- Plump, Gram-negative rod
- Faintly staining, small Gram-negative coccobacillus, “fine sand”

**Notes:**
Gram-positive bacillus, singly and in chains.
B. Faintly staining, very tiny Gram-negative coccobacillus seen mostly as single cells.
C. A plump, Gram-negative rod.
D. Faintly-staining, small Gram-negative coccobacillus appearing like “fine sand.”

## Plague Scenario LaboratoryQuestion 1

- What presentation would you expect on a Gram stain if this was plague?
- C.  Plump, Gram-negative rod

**Notes:**
The best answer is C.  A plump, Gram-negative rod (1.0-2.0 x 0.5 m) is indicative of Yersinia pestis, or plague.

Gram-positive bacilli presenting both singly and in chains is representative of Bacillus anthracis. 
The tiny Gram-negative coccobacilli seen mostly as single cells is representative of Francisella tularensis. 
The “fine sand” appearance of the small, Gram-negative coccobacilli is indicative of Brucella species.  (Although a small Gram-negative coccobacillus, cells are typically larger than those of F. tularensis.

## Plague Scenario LaboratoryQuestion 2

- Growth plates prepared
- Sheep blood agar
- What presentation would you expect to see after 48 hours?

**Notes:**
You prepared growth plates on sheep blood agar.
What presentation would you expect to see after 48 hours if this is plague?

## Plague Scenario LaboratoryQuestion 2

- What presentation would you expect to see after 48 hours?
- Slow growing, pinpoint, gray-white to opaque colonies, “fried egg”
- Growing poorly, 1-2mm, gray-white, non-hemolytic
- Slow growing, pinpoint, smooth, entire border, translucent, non-hemolytic
- Rapidly growing, non-pigmented, dry “ground glass” surface, flat or slightly convex, irregular edges with Medusa head

**Notes:**
A. Slow growing, pinpoint (1 to 2 mm), gray-white to opaque colonies with “fried egg” appearance.
B. Growing poorly, 1-2mm, gray-white, non-hemolytic.
C. Slow growing, pinpoint, smooth, with an entire border, translucent, non-hemolytic.
D. Rapidly growing, non-pigmented, dry “ground glass” surface, flat or slightly convex, irregular edges with Medusa head.

## Plague Scenario LaboratoryQuestion 2

- What presentation would you expect to see after 48 hours?
- Slow growing, pinpoint, gray-white to opaque colonies, “fried egg”

**Notes:**
The “fried egg” appearance can be characteristic of Yersinia pestis.  You should continue with the algorithm for plague.

The non-hemolytic appearance is characteristic of Francisella tularensis.
The presence of an entire border is indicative of Brucella species.
The characteristics described are representative of Bacillus anthracis.

## Plague Scenario LaboratoryQuestion 3

- Suspicious of *Y. pestis*
- Other, more definitive tests
- What other characteristics would you expect to see?

**Notes:**
You are now suspicious of Y. pestis.  You now move on to other, more definitive tests. 
What characteristics would you expect to see after 48 hours if this is plague?

## Plague Scenario LaboratoryQuestion 3

- What other characteristics would you expect to see?
- Hemolysis – None, Catalase (+), Non-Motile
- Oxidase (-), Catalase (+), Urea (-),
- 		Indole (-)
- Oxidase (-), Catalase Weak (+), -lactamase (+), Satellite (-), Urease (-)
- Oxidase (+), Urease (+), Satellite (-)

**Notes:**
A. Hemolysis – None; Catalase – Positive; Motility – Non-motile
B. Oxidase test – Negative; Catalase – Positive; Urea – Negative; Indole - Negative
C. Oxidase test – Negative; Catalase – Weak Positive; -lactamase – Positive; Satellite – Negative; Urease - Negative
D. Oxidase test – Positive; Urease – Positive; Satellite test - Negative

## Plague Scenario LaboratoryQuestion 3

- What other characteristics would you expect to see?
- Oxidase (-), Catalase (+), Urea (-),
-          Indole (-)

**Notes:**
The best answer is B.  These are characteristics of Yersinia pestis and should be reported as “unable to rule out Y. pestis.”  Specimens should be referred to the state public health laboratory for confirmation.

A is characteristic of Bacillus anthracis.
C is characteristic of Francisella tularensis.
D is characteristic of Brucella species.

## Questions for Veterinarians

## Plague Scenario VeterinarianQuestion 1

- Vet in small-animal practice
- Hartford, Connecticut
- Near ice hockey arena
- Domestic feline
- Owner suspects pneumonic plague
- What signs and symptoms would you expect to see?

**Notes:**
You are a veterinarian in a small-animal practice in Hartford, Connecticut, near the ice hockey arena.
A woman brings in her sick cat.  She has just watched a documentary on plague in animals and is convinced her cat has pneumonic plague.
What signs and symptoms would you expect to see if this were the case?

## Plague Scenario VeterinarianQuestion 1

- What signs and symptoms would you expect to see?
- Fever, respiratory difficulty, excitement and depression, vomiting, bloody diarrhea
- Depression, lymphadenopathy, abcesses, oral or lingual ulceration, anorexia
- Rapidly progressing illness, fever, cough bloody sputum

**Notes:**
A. Fever, respiratory difficulty, excitement followed by depression, vomiting, bloody diarrhea
B. Depression, lymphadenopathy, abscesses, oral or lingual ulceration, anorexia, weight loss
C. Rapidly progressing illness, fever, cough, bloody sputum

## Plague Scenario VeterinarianQuestion 1

- What signs and symptoms would you expect to see?
- C.  Rapidly progressing illness, fever, cough bloody sputum

**Notes:**
The best answer is C.  These signs and symptoms are indicative of pneumonic plague.

The other symptoms are indicative of anthrax and tularemia.

## Plague Scenario VeterinarianQuestion 2

- Domestic feline
- Signs and symptoms seem to match plague
- What kind of treatment would you begin on this cat?

**Notes:**
When you first saw the cat, you realized the  signs and symptoms seem to match plague.
What kind of treatment did you begin on this cat?

## Plague Scenario VeterinarianQuestion 2

- What kind of treatment would you begin on this cat?
- Gentamicin
- Penicillin
- Fluorquinolones

**Notes:**
Gentamicin
B.  Penicillin
C. Fluoroquinolones

## Plague Scenario VeterinarianQuestion 2

- What kind of treatment would you begin on this cat?
- A.  Gentamicin

**Notes:**
The best answer is A.  Gentamicin, 2-3mg, tid, IM or SQ, is the preferred treatment for plague in animals and can also be effective for other bioterror agents.

Penicillin has proven more useful in the treatment of anthrax. Fluoroquinolones have proven promising in the treatment of tularemia.

## Plague Scenario VeterinarianQuestion 3

- You suspect plague
- Lab specimens
- Pharyngeal swab
- Serology
- Lab results:  Unable to rule out *Y. pestis*
- What is your next step?

**Notes:**
Now that you suspect plague, you decide to obtain a pharyngeal swab, using a culturette.  You also decide to go ahead and get a serology on the cat, just in case.
The lab comes back unable to rule out Y. pestis.  What is your next step?

## Plague Scenario VeterinarianQuestion 3

- What is your next step?
- Send it to private reference laboratory
- Call public health
- Shut down your practice

**Notes:**
Ask your laboratory to send it on to your private reference laboratory.
B. Call your local public health agency.
C. Shut down your practice.

## Plague Scenario VeterinarianQuestion 3

- What is your next step?
- B.  Call public health

**Notes:**
The best answer is B.  You should contact public health immediately to report your findings.  This could be the first indication of a serious problem that could also affect humans.

Do NOT assume your laboratory will call public health.  Also, public health will need to confirm your findings.  Valuable time could be wasted if you send it on to your private reference laboratory. You do not need to shut down your practice.  But you do need to speak with public health in order to confirm the test results and get the cat’s owner and all exposed staff started on the appropriate antibiotic.