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Biological warfare

Biological warfare. Renaat A. A. M. Peleman, MD, PhD Dept Internal Med, Div Infect Dis University Hospital Ghent. Index of Suspicion. Are there an unusual number of patients presenting with similar symptoms? Is there an unusual presentation of symptoms?

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Biological warfare

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  1. Biological warfare Renaat A. A. M. Peleman, MD, PhD Dept Internal Med, Div Infect Dis University Hospital Ghent

  2. Index of Suspicion • Are there an unusual number of patients presenting with similar symptoms? • Is there an unusual presentation of symptoms? • Many cases of unexplained diseases or deaths • Patients presenting with similar set of exposures? • Diseases normally transmitted by vector not present in area • Is this an unexplained case of a previously healthy individual with an apparently infectious disease? • Disease outbreak with zoonotic impact

  3. Biological Agents of Highest Concern • Variola major (Smallpox) • Bacillus anthracis (Anthrax) • Yersinia pestis (Plague) • Francisella tularensis (Tularemia) • Coxiella burnetii ( Q Fever) • Botulinum toxin (Botulism) • Filoviruses and Arenaviruses (Viral hemorrhagic fevers) • Report ALL suspected or confirmed illness due to these agents to health authorities immediately

  4. Why These Agents? • Infectious via aerosol • Organisms fairly stable in aerosol • Susceptible civilian populations • High morbidity and mortality • Person-to-person transmission (smallpox, plague, VHF) • Difficult to diagnose and/or treat • Previous development for BW

  5. Nominal lethality/1,000 kgs of different biological weapens

  6. Motivation Number of casualties Level of panic Capabilities Group size Technical proficiency Financial resources Agents Availability Ease of growth Morbidity & mortality Dissemination Ease of dissemination Efficacy of dissemination technique Target Number exposed at target Target vulnerability The bioterrorism pathways matrix

  7. Covert vs. Overt Event Overt Covert Recognition Early Delayed Response Early Delayed Treatment Early Delayed Responders Traditional First Health Care Responders Workers

  8. Diagnostic matrix:chemical and biological casualties

  9. Inhalational Anthrax, Plague, Tularemia:Differential Diagnoses • Community acquired pneumonia (CAP) • S. pneumoniae, H. influenzae, Klebsiella spp • Pneumonic Anthrax, Tularemia, Plague, Melioidosis • Brucellosis, Q Fever, Histoplasmosis • Severe atypical CAP (Legionella, Mycoplasma) • Hantavirus pulmonary syndrome (HPS)

  10. inhaled BWF bacteria • Treatment • Fluoroquinolones (all) • Vibramycin • Penicillin • Aminoglycosides • Prophylaxis • Fluoroquinolones (all) • Vibramycin

  11. 1 - 6 days ABRUPT ONSET GI Anthrax Disease Complex Summary Inhalational Tracheobronchial Lymphadenitis Cutaneous Mediastinitis, cyanosis, stridor, pulmonary edema Hemorrhagic Meningitis Papule Õ vesicle edema + eschar 50% 24 - 36 hours Toxic shock and Death 20% Resolve

  12. BacteriaBacillus anthracis • Disease: anthrax • Incubation: 1 – 60 days • Length of illness:1 to 2 days • Mortality rate: extremely high, death typically occurs within 24 – 36 hours after onset of severe symptoms • Effective dosage: 8.000-50.000 spores • casualties/50 kg/city/5*106: 250.000

  13. MMWR-Weekly, November 02, 2001 / 50(43);941-8

  14. MMWR-Weekly, November 02, 2001 / 50(43);941-8

  15. Chest Radiograph • Inhalation Anthrax • Note: • widened mediastinum • diminished air space

  16. Inhalational anthrax: evolution

  17. Anthrax Case 3 / October, 2001

  18. Anthrax Case 3/ October, 2001

  19. Anthrax Case 4 / October 19, 2001

  20. Anthrax Case 4 / October 19, 2001

  21. Anthrax Case 4 / October 19, 2001

  22. Anthrax Case 4 / October 19, 2001

  23. Anthrax Case 4 / October 19, 2001

  24. Specimen Collection: B. anthracis

  25. Cutaneous Anthrax • black eschar (anthracis, Greek for “coal”) • typical red areola Arm Neck

  26. Cutaneous anthrax, stemming from wear of infected wool scarf

  27. Hemorrhagic Meningitis Human autopsy, 1979, Sverdlovsk, hemorrhagic meningitis 2° to inhalation anthrax

  28. Plague Disease Complex Erythema Fever/rigors ­ APTT ecchymosis DIC Tender bubo 1 - 10 cm Inhalational Pharyngitis 2 -3 days Sudden onset 9% 2 - 10 days 24 hrs Systemic Toxicity Fever, URI syndrome Stridor, cyanosis, productive cough, bilateral infiltrates Fulminant Pneumonia 6% late meningitis Liver enzymes ­­ Leukemoid reaction Respiratory failure & circulatory collapse Gram - ve rods in sputum

  29. Pneumonic Plague: Prevention of Secondary Infection • Secondary transmission is possible and likely • Standard, contact, and droplet precautions for at least 48 hrs until sputum cultures are negative or pneumonic plague is excluded

  30. Plague: Specimen Collection

  31. Clinical clues

  32. Bubonic Staph/streptococcal adenitis Glandular tularemia Cat scratch disease Septicemic Other gram-negative sepsis Meningococcemia RMSF TTP Pneumonic Bioterrorism threats Anthrax Tularemia Melioidosis Other pneumonias (CAP, influenza, HPS) Hemorrhagic leptospirosis Plague: Differential Diagnosis

  33. Primary pulmonary + 2 wks duration Tularemia Disease Complex Summary Oropharyngeal pseudomembrane Papule®ulcer cutaneous lesions Inhalational Conjunctiva 2 - 10 days 50% Secondary pleuropulmonary Abrupt onset Fever, chills headaches Alveolar septa Necrosis & cavitation 7 - 10 days Rhabdomyolysis Infiltrates, rales Mild liver enzyme ­ Lower nephrotic syndrome

  34. Specimen Collection: F. tularensis

  35. Q Fever – Clinical Course Summary CNS symptoms and neck stiffness Meningitis Inhalation Osteomyelitis Sudden onset Mild primary atypical pneumonia “ground glass” Fever (100 - 104º 3 - 6 days), malaise, anorexia + headache Late complications 2 - 14 day course Chronic infective endocarditis (aortic valve) Mild ­ LFT

  36. Q fever: Clinical Features 3 DAYS LATER AT PRESENTATION

  37. Specimen Collection: Q. Fever

  38. Clinical clues

  39. RickettsiaeCoxiella burnetti • Symptoms: acute non-differentiated febrile illness with cough, aches, fever, chest pain, pneumonia • Leukocytosis in 30%, elevated LFT • Prophylaxis: • Vaccine available • Chemoprophylaxis:Doxycycline 100 mg bid for at least 7 days but start only 8 – 12 days post exposure. If started too early, prophylaxis prolongs the disease • Treatment: Doxycycline 100 mg bid for 5 - 7 days

  40. Exanthema on face, arms, hands Macules ®papules ® pustular vesicles Smallpox - Clinical Course Summary Inhalational 8 - 10 days Replication in regional node of airways 12 day incubation Scabs separate + pt non-infective 2 - 3 days Flat Smallpox Viremia Acute malaise, fever, rigors, headache variants Hemorrhagic Smallpox rapid death before typical lesions + mental status changes

  41. Smallpox: Clinical Features USAMRICD

  42. Smallpox: Clinical Features USAMRICD

  43. Incubation 7-17 days 14-21 days Prodrome 2- 4 days minimal/none Distribution centrifugal centripetal Progression synchronous asynchronous Scab formation 10-14 d p rash 4-7 d p rash Scab separation 14-28 d p rash <14 d p rash Smallpox vs. Chickenpox Varicella Variola

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