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Bioterrorism Agents – Plague Lesson 8

Bioterrorism Agents – Plague Lesson 8. Scenarios and Questions. Overview. Developing scenario Questions to review knowledge Additional questions for laboratorians and veterinarians. Plague Scenario Question 1. Physician in Hartford, Connecticut 35yo male, no underlying

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Bioterrorism Agents – Plague Lesson 8

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  1. Bioterrorism Agents – PlagueLesson 8 Scenarios and Questions

  2. Overview • Developing scenario • Questions to review knowledge • Additional questions for laboratorians and veterinarians

  3. 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?

  4. 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

  5. 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

  6. 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?

  7. 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

  8. 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

  9. 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?

  10. 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

  11. Plague Scenario Question 3 What is your next step? C. Call public health

  12. Plague Scenario Question 4 • You’ve contacted your hospitals infection control practitioner What should your infection control practitioner recommend to you?

  13. 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

  14. 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

  15. Plague Scenario Question 5 • Asked to obtain travel history If it’s naturally-acquired, where would he have traveled?

  16. Plague Scenario Question 5 If it’s naturally-acquired, where would he have traveled? • Australia • Canada • Western United States • Northeast United States

  17. Plague Scenario Question 5 If it’s naturally-acquired, where would he have traveled? C. Western United States

  18. Plague Scenario Question 6 • Consulted with public health • All specimens they need have been collected What treatment regimen would you consider?

  19. Plague Scenario Question 6 What treatment regimen would you consider? • Gentamicin • Ampicilin • Tetracycline • Bactrim

  20. Plague Scenario Question 6 What treatment regimen would you consider? • Gentamicin

  21. 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?

  22. 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

  23. Plague Scenario Question 7 What will public health ask you to do to help manage this outbreak? C. Conduct chart review

  24. 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?

  25. 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

  26. 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

  27. 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?

  28. 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

  29. Plague Scenario Question 9 What is one of the medications you will use for your adult patients? B. Doxycycline – 100mg PO BID

  30. Questions for Laboratorians

  31. Plague Scenario LaboratoryQuestion 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?

  32. Plague Scenario LaboratoryQuestion 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”

  33. Plague Scenario LaboratoryQuestion 1 What presentation would you expect on a Gram stain if this was plague? C. Plump, Gram-negative rod

  34. Plague Scenario LaboratoryQuestion 2 • Growth plates prepared • Sheep blood agar What presentation would you expect to see after 48 hours?

  35. Plague Scenario LaboratoryQuestion 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

  36. Plague Scenario LaboratoryQuestion 2 What presentation would you expect to see after 48 hours? • Slow growing, pinpoint, gray-white to opaque colonies, “fried egg”

  37. Plague Scenario LaboratoryQuestion 3 • Suspicious of Y. pestis • Other, more definitive tests What other characteristics would you expect to see?

  38. Plague Scenario LaboratoryQuestion 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 (-)

  39. Plague Scenario LaboratoryQuestion 3 What other characteristics would you expect to see? • Oxidase (-), Catalase (+), Urea (-), Indole (-)

  40. Questions for Veterinarians

  41. Plague Scenario VeterinarianQuestion 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?

  42. Plague Scenario VeterinarianQuestion 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

  43. Plague Scenario VeterinarianQuestion 1 What signs and symptoms would you expect to see? C. Rapidly progressing illness, fever, cough bloody sputum

  44. Plague Scenario VeterinarianQuestion 2 • Domestic feline • Signs and symptoms seem to match plague What kind of treatment would you begin on this cat?

  45. Plague Scenario VeterinarianQuestion 2 What kind of treatment would you begin on this cat? • Gentamicin • Penicillin • Fluorquinolones

  46. Plague Scenario VeterinarianQuestion 2 What kind of treatment would you begin on this cat? A. Gentamicin

  47. Plague Scenario VeterinarianQuestion 3 • You suspect plague • Lab specimens • Pharyngeal swab • Serology • Lab results: Unable to rule out Y. pestis What is your next step?

  48. Plague Scenario VeterinarianQuestion 3 What is your next step? • Send it to private reference laboratory • Call public health • Shut down your practice

  49. Plague Scenario VeterinarianQuestion 3 What is your next step? B. Call public health

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