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By Dag K.J.E. von Lubitz

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Extra info for Bioterrorism: Field Guide to Disease Identification and Initial Patient Management

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Lesions are discovered frequently during autopsies. E. 9oC or 105oF), tachycardia, tachypnea, and hypotension. E. fm Page 37 Friday, August 8, 2003 8:14 AM Laboratory Tests Ⅲ CBC: white blood count (WBC) elevated to 20,000 or greater; left shift is noted; WBC may be low in late septicemia Ⅲ Urinalysis: gross hematuria; red blood count (RBC) casts; proteinuria Ⅲ Arterial blood gas: possible hypoxia and/or acidosis Ⅲ Microscopy: smears from lymph node (bubo) aspirate, sputum, blood, or CSF Ⅲ Gram stain: Gram-negative pleomorphic coccobacilli Ⅲ Wright, Giemsa, and Wayson’s stains also useful; bipolar “safety-pin” structure Ⅲ Definitive diagnosis relies on culturing bacteria from blood, sputum, CSF, or bubo aspirates: – Slow growth: > 48 hours before cultures can be definitively identified – Optimal growth at 28∞C – Blood and bubo cultures positive in majority of patients (> 85%) – Sputum cultures positive only if lung involvement present Ⅲ Fluorescent antibody stain provides rapid diagnosis Ⅲ Fluorescent antibody titer: fourfold titer difference indicates infection Ⅲ PCR: insufficiently developed but very sensitive Ⅲ Laboratory procedures generating aerosols require Biosafety Level 3 containment; otherwise Biosafety Level 2 offers sufficient protection Treatment Plague is almost always fatal unless treatment is initiated within 24 hours of the onset of symptoms.

Fm Page 35 Friday, August 8, 2003 8:14 AM Clinical Features A sudden increase in the number of patients presenting with severe, rapidly progressing pneumonia with hemoptysis suggests outbreak of plague. However, diagnosis may be extremely difficult in individual patients presenting without bubos, especially in nonendemic regions. Differential diagnosis may be complex. Demonstration of Gram-negative bacilli in the sputum indicate Y. pestis infection — the only Gram-negative bacterium that causes fulminant pneumonia with bloody sputum.

In other countries, consumption of unpasteurized dairy products (cheese in particular) is the main reason for high incidence of brucellosis. Human-to-human transmission has not been reported, but high infection rates through inhalation are reported among laboratory workers involved in culturing Brucellae. Due to the highly infective potential of aerosol-dispersed Brucellae and symptoms that can be easily misdiagnosed as influenza, brucellosis represents a significant potential threat. E. E. fm Page 24 Friday, August 8, 2003 8:14 AM Laboratory Tests Ⅲ Complete blood count (CBC) Ⅲ Blood and bone marrow cultures give yields sufficient for definitive identification Ⅲ Antibody testing (most reliable method) Ⅲ Agglutination test (titers of 1:160 indicate positive diagnosis) Ⅲ Enzyme-linked immunosorbent assay (ELISA) Ⅲ Urine analysis and culture; sterile pyuria Ⅲ Arthrocentesis (excluding septic arthritis) Ⅲ Chest x-ray (usually normal) Ⅲ Cranial CT scan if altered mental status or focal neurological deficits are apparent; brucella-induced leptomeningitis, subarachnoid hemorrhage, or cerebral abscess may be present Treatment Oral antibiotics: consult an infectious disease specialist for defi nitive regimen.

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