2. Ä On October 2, 2001
0 a 63-year-old Caucasian photo editor
working for a Florida newspaper
o awoke early with nausea, vomiting, and
confusion and was taken to a local
emergency room for evaluation
3. P His illness, which started on September
27 during a trip to North Carolina
characterized by malaise, fatigue, fever,
chills, anorexia, and sweats
, No history of headache, cough, chest
pain, myalgias, dyspnea, abdominal
pain, diarrhea, or skin lesions
4. ΠPatient was alert and interactive but
spoke nonsensically
l He was not oriented to person, place, or
time
t BT 39.2°C HR 109/min BP 110/80 RR
14/min
0 Initial pulmonary, heart, and abdominal
examinations were normal
e No nuchal rigidity
5.
6. CBC: Hct 45.7 WBC 9400 N 76% L15%
Plt 109,000
C Na 132 K 3.5 Cl 110 HCO3 24
1 UA :no RBC,WBC
7.
8. l prominent superior mediastinum and
small left pleural effusion
16. The patient died on October 5
Autopsy findings
hemorrhagic mediastinal lymphadenitis
immunohistochemical staining showed
disseminated B. anthracis in multiple organs
17.
18. l a 59-year-old Caucasian man, contract
employee at a U.S. State Department
mail sorting facility that received mail
from the District of Columbia postal
facility became ill
19. He had drenching sweats
2 days of fever with chills,severe
myalgias
w cough with scant white sputum
substernal chest pain
nausea, vomiting, abdominal pain
20. BT 38.2°C HR 116/min BP 120/70 RR
16/min
/ oxygen saturation 94% (room air)
n He appeared ill and had decreased
breath sounds at the right base
The rest of the examination was
unremarkable
21. ì Hematocrit 48.1%
ì WBC count 9,500/mm3 ( 81% N, 9% L
9% M)
m Platelet count 196,000/ mm3
9 Normal electrolytes and creatinine
25. Mediastinal adenopathy with evidence of
hemorrhage
Normal lung parenchyma
Small bilateral pleural effusions
Suspected small pericardial effusion
26. ° Intravenous penicillin
c Rifampin
c Ciprofloxacin
c Vancomycin
27.
28. Features that should alert possibility
of bioterrorism-related outbreak
r A rapidly increasing disease incidence
(e.g., within hours or days) in a normally
healthy population
o An epidemic curve that rises and falls
during a short period of time
t especially with fever, respiratory, or
gastrointestinal complaints
29. Features that should alert possibility
of bioterrorism-related outbreak
An endemic disease rapidly emerging at an
uncharacteristic time or in an unusual pattern
Lower attack rates among people who had
been indoors
especially in areas with filtered air or closed
ventilation systems compared with people who
had been outdoors
s Clusters of patients arriving from a single locale
30. Features that should alert possibility
of bioterrorism-related outbreak
Large numbers of rapidly fatal cases
s Any patient presenting with uncommon
disease and has bioterrorism potential
Pulmonary anthrax
Tularemia
Plague
31. Ä The U.S. Public health system and primary
healthcare providers must be prepared to
address various biological agents
b pathogens that are rarely seen in the united
states
r High-priority agents include organisms that
pose a risk to national security
32. P Category A agents
Can be easily disseminated or transmitted
from person to person
Result in high mortality rates and have the
potential for major public health impact
Might cause public panic and social
disruption
Require special action for public health
preparedness
33. • Anthrax (bacillus anthracis)
i Botulism (clostridium botulinum toxin)
1 Plague (yersinia pestis)
H Smallpox (variola major)
a Tularemia (francisella tularensis)
r Viral hemorrhagic fever
filoviruses [Ebola, marburg]
arenaviruses [Lassa, machupo]
34. Biological weapon
In year 2001, US
Anthrax was deliberately spread through the
postal system by sending letters with powder
containing anthrax
22 cases of anthrax infection
35. P Bacillus anthracis
i a gram-positive spore-forming
bacterium
s “woolsorters'disease”
a a disease of sheep, cattle, and horses
36.
37. The spores are extremely hardy and can
survive for years
s The disease is caused by exposure to
the spores, not the bacilli in their
vegetative state
38. The spores germinate into bacilli inside
macrophages
n Releasing toxins
protective antigen
edema factor
lethal factor
O cause edema and cell death
39. Skin : cutaneous anthrax
x Lung : inhalation anthrax
Breathing in anthrax spores from infected
animal products like wool
l GI tract : gastrointestinal anthrax
Eating undercooked meat from infected
animals
40.
41. Incubation period
d ranges from 1day to 8 weeks (average
5days) depending on the exposure route
and dose
2-60 days following pulmonary exposure
1-7 days following cutaneous exposure
1-7 days following ingestion
42. 0 the most lethal form of the disease
f caused by inhaling spores into the lungs
n the spores germinate and are
transported to the tracheobronchial
lymph nodes
43. Initial phase
ð flulike illness with malaise
w nonproductive cough, chest discomfort
u initial phase can be delayed for more
than a month in some patients
s 50% of patients develop hemorrhagic
meningitis
44. Within 24 to 48 hours
h abrupt deterioration
Overwhelming sepsis
Dyspnea, stridor
Shock
Hemorrhagic mediastinitis
45. ΠChest radiograph show a widened
mediastinum and hilar adenopathy
47. CT chest is more sensitive
Bloody pleural effusions
consolidation of the lung fields
48. H Clinical diagnosis
Flulike or septic illness
c A reason to consider anthrax in the first
place
Current outbreak, warning from authorities
, Sputum culture, gram stain, and blood
cultures are not helpful until late in the
course of the disease
49. Tests to confirm the diagnosis
PCR for identification of anthrax markers
in pleural fluid
i serologic detection of immunoglobulin to
protective antigen
e Immunohistochemical testing of biopsy
specimens
51. spores are introduced into the skin
through open wounds or abrasions
n After I.P. 1 to 5 days
5 Begins as a papule usually on an
exposed area
the head, neck, or an upper extremity
o The papule may resemble an insect or
spider bite and may itch
52. a papule progressing to form a large
vesicle over the next several days
e Severe edema occurs around the lesion
with regional lymphadenitis
m The lesions are not tender
m patient may or may not be febrile
55. After about 1 week
ü the lesion ruptures, forming a black
eschar
r surrounding erythema and edema
increase
h The necrotic ulcer is usually painless
57. Forearm lesion on day 7
n vesiculation and ulceration of initial macular or
papular anthrax skin lesion
58. h Eschar of the neck on day 15, typical of the
last day of lesion
59.
60.
61. In the next 2 to 3 weeks
ü the eschar sloughs off
f the organism disseminates and the
patient dies
62. The mortality rate
20% without treatment
1% with treatment
t Antibiotics do not affect the course of
local disease
e but are used to prevent dissemination
and death
63. H Clinical diagnosis.
i Confirmation
Culturing of the lesion, punch biopsy,or
serologic testing
64. l Rare manifestations
o The ingestion of insufficiently cooked,
contaminated meat
t the spores are transported to regional
lymphatic tissue
r I.P 2- 5 day
r The mortality rate is 50%
65. 0 Present with sore throat and neck
swelling from cervical and
submandibular lymphadenitis
m The tonsils are frequently involved
i Fever and toxicity
t Dysphagia
t Respiratory distress
66. ΠBegins with nausea, vomiting, and fever
e Hematemesis
e Ascites
e Bloody diarrhea
e Mesenteric lymphadenitis
a Present with an acute abdomen
69. , Death usually results within 3 days
s The mortality rate was thought to
exceed 90%
70. ΠInactivated, cell-free anthrax vaccine
l There is a vaccine to prevent anthrax, but it
is not yet available for the general public
a Anyone who may be exposed to anthrax
Certain members of the US
Armed forces
Laboratory workers
Workers who may enter contaminated areas
In the event of an attack using anthrax as a
weapon, people exposed would get the vaccine
71. ˆ Human-to-human transmission has not
been reported with inhalational anthrax
t Airborne transmission does not occur,
but direct contact with skin lesions may
result in cutaneous infection
72.
73.
74.
75.
76. è Yersinia pestis
à gram-negative bacterium
c Zoonotic disease is transmitted to
humans by the bites of infected rodent
fleas
77. Male Xenopsylla cheopis (oriental rat flea) engorged with
blood. This flea is the primary vector of plague in most large
plague epidemics in Asia, Africa, and South America
78. è suggestive of exposure to rodents,
rodent fleas, wild rabbits, sick or dead
carnivores, or patients with pneumonic
plague.
a Incubation period is 1–6 days
79.
80.
81. , Specimens
bubo aspirates, blood cultures, sputum
culture if pneumonic
o Microscopic identification
t culture confirmation
t Serologic tests
fourfold change in antibody titer to f1 antigen
between acute- and convalescent-phase sera
82. Physicians should report all suspected
plague cases to state or local health
departments and/or consult with CDC to
obtain information and access
diagnostic services.
85. ì No vaccine is currently available in the
united states.
i aimed at reducing contact with fleas and
potentially infected rodents and other
wildlife
86.
87. Generated by the infected patient during
coughing, sneezing, talking during
respiratory-care procedures
88. Healthcare providers and others should
wear a surgical-type mask when within 3
feet of the infected patient
c Some healthcare facilities require a
mask be worn to enter the room of a
patient on droplet precautions
91. Maintaining spatial separation of at least
3 feet between infected patients and
others when cohorting is not achievable.
r Avoiding placement in the same room
with an immunocompromised patient.
m Special air handling is not necessary
and doors may remain open
92. 0 Prophylactic antibiotic treatment in
person who exposure to
bites of wild rodent fleas during an outbreak
tissues of a plague-infected animal
person or animal with suspected plague
pneumonia
93.
94.
95.
96.
97.
98.
99.
100.
101.
102.
103.
104.
105.
106.
107.
108.
109.
110. Contact precautions
Wear clean gloves upon entry into patient
room.
Wear gown for all patient contact and for all
contact with the patient’s environment.
Require a gown be worn to enter the room of
a patient.
Gown must be removed before leaving the
patient’s room.
Wash hands using an antimicrobial agent
111.
112. Healthcare facilities without patient
rooms appropriate for Airborne
Precautions
e should have a plan for transfer of
suspected or confirmed smallpox
patients to neighboring facilities with
appropriate isolation rooms
113.
114.
115. Ð Fever, headache and stiff neck
a sepsis and rash in meningococcemia
116. H N. meningitidis colonizes mucosal
surfaces of nasopharynx
p direct contact with large droplet
respiratory secretions from the patients
or asymptomatic carriers
c Humans are the only host
117. H Patients with meningococcemia should
be placed in respiratory isolation for at
least 24 hours.
118. H Close contacts should receive antibiotic
prophylaxis.
h Household, nursery school, and daycare
center contacts
r Intimate contacts and health care workers
with intimate exposure
mouth-to-mouth resuscitation, intubation,suctioning
119. Rifampin, 10 mg/kg (up to 600 mg)
orally every 12 hours for four doses
h The dose for infants younger than 1
month is 5 mg/kg.
. Rifampin discolors the urine
r Contact lenses should be removed to
avoid permanent staining.
120. Ceftriaxone IM is effective against group
A strains.
125 mg for children younger than 12 years
250 mg for those older than 12 years
alternative for pregnant women and for
people in whom compliance cannot be
ensured.
o Ciprofloxacin (500 mg orally)
121. È Meningococcal vaccine should be
considered
adjunct to prophylaxis in epidemics
close contacts in sporadic cases
n The currently available vaccine is a
quadrivalent vaccine
containing purified capsular polysaccharides
for groups A, C, Y, W
122. No vaccine exists for group B
the most prevalent serogroup in the United
States.
123. The quadrivalent vaccine is not
recommended for routine use
r but should be administered to
children 2 years of age
older in high-risk groups
functional or anatomic asplenia
terminal complement deficiency
124. The vaccine is currently administered to
U.S. military recruits.
c Consideration in people traveling to
endemic areas of the world such as sub-
Saharan Africa.
