Bioterrorism – Flashcards

Clusters of patients from single locale Rapidly increasing disease incidence Endemic disease rapidly emerging at unusual time or pattern Any patient presenting with a disease that is uncommon and has bioterrorism potential

- Easily disseminated (anthrax) OR - Transmitted person to person (smallpox) OR - High mortality w/ potential for major public health impact

- Bacillus anthracis (anthrax) - Variola major (smallpox) - Clostridium botulinum (botulism) - Yersinia pestis (plague) - Francisella tularensis (tularemia) - Hemorrhagic fever viruses

Coxiella burnetti (Q fever) Brucella species (brucellosis) Burkholderia mallei (glanders) - animal disease Alphaviruses (VEE, EEE, WEE, others) Toxins: ricin, Staph. Enterotoxin B (would be more dangerous for older or immunocompromised people) Food and waterborne pathogens

- These could cause serious disease but they aren't as easy to manipulate into a form that could be weaponized.

- acquired usually by contact with infected animals or their hides - Bacillus anthracis - It can be weaponized via using the spore forms

- Gram (+) - Aerobe - Rod - Non-motile - Non-hemolytic - Spore former (can survive for decades) - germinate when the environemtn is rich in nutrients - Inhalational, Cutaneous, and Gastrointestinal

- LD50 estimated to be 8,000 to 10,000 inhaled spores - Sounds like a lot. The problem is when this is weaponized, the particles are extremely small and are well suspended in air (wouldn't see a cloud) - you could easily get this number of spores from inhalation of air with spores in it. - Spores inhaled --> Uptake of spores by pulmonary macrophages which carry spores to tracheobronchial or mediastinal lymph nodes (where the blood supply is very good and there is a high O2 tension) - they then go from the spores to the highly replicating bacteria;

Antiphagocytic Capsule Edema factor (EF) Lethal Factor (LF) Protective antigen (PA)

- It uses its toxins (edema and lethal factor) to cause this necrosis which allows it to cause a massive "overwhelming" septicemia - Septicemia causes the hemodyamic collapse and hypotension

- usually 1-16 days but can be up to 60 days - Nonspecific flu like illness (Fever, myalgia, headache, nonproductive cough, mild chest discomfort, nausea, vomiting) --> respiratory failure and shock. - hemorrhagic meninigitis (CSF has alot of red cells) - >90% historically (now more like 40%) -** Widened mediastinum** (due to massive edema and necrosis of the mediastinal and hilar lymph nodes); Other = possible pleural effusions; infiltrates - Gram stain showing bacilli in blood would be very bad because if you can see them without culturing before, their inoculum must be very high. Blood cultures will grow in 6-24 hrs. - G(+) rods in chains

- Cutaneous - most common form - Local skin involvement after direct contact of abraded skin with spores - Starts as papule, then vesicle, then **depressed black eschar** (w/ lots of edema surrounding it) - Mortality 20% without therapy; rare with therapy (~curable) - Usually require IV therapy

- the depressed black eschar lesion forms and the area has massive edema - Follows ingestion of insufficiently cooked contaminated meat - Severe abdominal distress, followed by fever and signs of septicemia - 25-60% mortality

- **Ciprofloxacin IV or Doxycycline IV** empirically, until sensitivities known. - BOTH adults and children (rules don't apply for bioterrorism) - for 60 days - Treat seriously ill patients with combination therapy - Because of concern of beta-lactamases, penicillin and ampicillin should not be used alone - Prophylaxis = Same 2 drugs (Doxy + Ciprofloxacin) - There is a inactivated licensed vaccine that requires multiple doses (limited availability and only used for military in high risk areas)

- Standard precautions for HCW's - Isolation NOT required (in reality might until you are sure what they have) - No person-to-person transmission - Instrument and area disinfection with sporicidal agent - chlorine - Decontamination of skin: use soap and water

Spores small, spread widely in aerosol No atmospheric warning signs to detect an aerosol cloud of anthrax spores First sign of large scale attacks via aerosol likely to be patients presenting with symptoms of inhalation anthrax

- Large DNA variola virus (not any natural cases since 1977) - High case fatality rate (30%) - We don't know the mortality rate now because we have lots of immnocompromised patients and we don't give the vaccine anymore (no immunity exists) - we are HIGHLY susceptible - HIGHLY transmissible (airborne aerosol/droplet nuclei from oropharynx and direct contact) - REQUIRES AIRBORNE AND CONTACT ISOLATION - Physically disfiguring - Vesicles scar over if the patient survives - No specific therapy - just supportive. - 7-17 days (longer than most viruses)

- Nonspecific before the rash starts (high fever, malaise, prostration with headache, backache --> Severe abdominal pain, delirium) **RASH** --> Maculopapular rash appears first on mucosa of mouth, pharynx, face and forearms, spreading to trunk and legs; The lesions have an **umbilicated and depressed appearance** - Rash becomes vesicular and then pustular - Pustules are very tense and deep in the dermis (different from the superficial vesicles of chickenpox) - There is one wave of viremia and the rash becomes vesicular and then pustular (thus have one wave and all the lesions will be at the same stage - not the same as something like chickenpox which has multiple stages of lesions because of multiple stages of viremia); **Thus the Rash is SYNCHRONOUS** - rash crusts over by 8-9 days and separate and the scar - Patients die from the toxemia - septicemia from the organism. The organisms is caused cytokine release etc leading to cardiovascular collapse. - Monkey pox is a DNA virus that is not a bioterrorism threat - it is a zoonoses - outbreak in US due to bringing over exotic monkeys. The lesions can mimic smallpox but has **diffuse lymphadenopathy** - this doesn't occur in smallpox or chickenpox.

Diagnosis: suspect clinically; Then send specimens to State lab, CDC: PCR of tissue available; Observing typical virions by electron microscopy Viral antigens, culture - Isolation - strict airborne and contact + Supportive care - No specific antiviral agent yet Wash contaminated surfaces - e.g. hypochlorite bleach.

- The vaccine is not based on the smallpox virus. It is related to vaccina virus. This is an intradermal vaccine. **does NOT reliably confer the immunity** - This disease is eradicaed - no natural cases since 1977. The virus still exists in certain labs, but the vaccine is no longer used. The vaccine may be given in the military due to bioterrorism concerns. The vaccine will protect for 5-10 yrs. It does not confer definite life time immunity. **specific contraindications** = Immunocompromised + Pregnant + Certain skin diseases (psoriasis, atopic dermatitis, eczema, etc) - They would get disseminated vaccinia (don't get smallpox from the vaccine). Still has a high mortality but does NOT cause smallpox. - give vaccine alone (also give to close contacts) - >3 days --> give vaccine + VIG (vaccinia immune globulin) - to the patient + their close contacts

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- Honey or Kayro syrup

- Foodborne form (intoxication) - 7 types; antitoxin covers only like 3 antigens (trivalent) + Support - Patient is responsive and LACKS fever - CN motor weakness (blurred vision, diplopia, **symmetric cranial neuropathies** **descending weakness** in proximal to distal pattern (different than others like Guillan barre/polio, etc) --> death resulting from respiratory dysfunction (failure) - NO sensory deficit - 12-72 hrs - NO

- Streptomycin and Gentamicin - Same as Anthrax = Doxycycline and Ciprofloxacin

- Yersinia pestis, a gram negative bacillus, often bipolar staining (little more stain on each end) - Rodents - Bubonic (regional lymphadenopathy) - Septicemic - just sepsis type presentation - Pneumonic - would be most likely form in bioterrorism event, and resulting from aerosol exposure - Suptum cultures and blood cultures - fever, weakness, cough, SOB,cough, hemoptysis, chest pain (fairly nonspecific) - depends on the syndrome - bubonic form has the large bubos lymphadenopathy also supprating --> course usually fulminating - Droplet isolation (falls w/in 3-5 feet) - requires airborne isolation for the first 48 hrs. - If pneumonic form - you might see the infiltate, but there is nothing very specific about this - just any typical infiltrate

- Septicemia can result in a necrosis of the digits and a purpuric rash that can mimic meningococcemia

- pneumonic form - thus probably aersolized - would be the easiest to transmit - Would cause severe disease of the lungs and pleura - NONSPECIFIC - Fever, sweats, cough, shortness of breath, chest pain, hemoptysis (specific types eg oculoglandular, ulceroglandular, typhoidal, etc have more specific findings) - via pneumonic form - just forms very severe pulmonary illness - Culutre and special stains/serology; Problem with culture is that it is very infectious - Same as plague - Streptomycin and gentamicin (alt = doxy or cipro) - **NO PERSON TO PERSON TRANSMISSION** (no isolation)

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