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Plague ˈplāg

(Black Death)

By Larry M. Bush, MD, Affiliate Professor of Clinical Biomedical Sciences; Affiliate Associate Professor of Medicine, Charles E. Schmidt College of Medicine, Florida Atlantic University; University of Miami-Miller School of Medicine

Plague is a severe infection caused by the gram-negative bacteria Yersinia pestis.

  • The bacteria are spread mainly by the rat flea.

  • Depending on the form, plague can cause fever, chills, swollen lymph nodes, headache, a rapid heartbeat, cough, difficulty breathing, vomiting, and diarrhea.

  • Identifying the bacteria in samples of blood, sputum, or pus from lymph nodes confirms the diagnosis.

  • Antibiotics can reduce the risk of death, and isolating infected people helps prevent spread of plague.

In the past, massive plague epidemics, such as the black death of the Middle Ages, killed many people. The main contributing factors were large numbers of rodents, urban crowding, and poor sanitation.

Plague now occurs mostly in rural areas. In the United States, more than 90% of infections occur in southwestern states such as Arizona, California, Colorado, and New Mexico, particularly among campers. Each year, plague affects about 10 to 15 people in the United States and 1,000 to 3,000 people worldwide.

The bacteria that cause plague usually infect wild rodents, such as rats and prairie dogs. The bacteria are spread by the rat flea. When wild rats die, the fleas may move to rats that live close to people, then to household pets, especially cats. The rat fleas may then bite people and transmit infection. Rarely, the infection is spread from person to person by inhaling droplets dispersed by coughing or sneezing. The bacteria lodge in the lungs and cause a type of pneumonia (pneumonic plague). Spread between people usually happens only when people live with or care for a person with pneumonic plague.

Plague bacteria are a potential biological weapon. The bacteria can be spread through the air and inhaled. The size of the airborne particle determines where the bacteria lodge in the respiratory tract. Small particles lodge in the lungs, causing pneumonic plague.

Other Yersinia infections

Infections caused by other Yersinia bacteria can also be acquired by handling infected animals (for example, by hunters) or by eating undercooked meat from infected animals.

These infections commonly cause diarrhea, which usually resolves on its own, and sore throat. Lymph nodes in the abdomen become inflamed, causing pain in the lower right part of the abdomen. The pain resembles the pain of appendicitis.

The bacteria may infect the bloodstream and other structures, including the joints (causing reactive arthritis). Reactive arthritis causes pain and swelling, usually in the hips, knees, and Achilles tendon.

Antibiotics are needed if the infection has spread to the bloodstream.

Symptoms of Plague

Plague has several forms:

  • Bubonic

  • Pestis minor

  • Pneumonic

  • Septicemic

Symptoms vary depending on the form of plague.

Bubonic plague

Bubonic plague is the most common form.

Bubonic plague symptoms may appear a few hours to 12 days after exposure (typically, after 2 to 5 days). Chills and fever of up to 106° F (41° C) occur suddenly. The heartbeat becomes rapid and weak, and blood pressure may drop. Many people become delirious.

Shortly before the fever or at the same time, lymph nodes in the groin, armpits, or neck usually swell. The swollen lymph nodes are called buboes. They are firm, red, warm, and very tender. During the second week, pus may drain from the lymph nodes. The liver and spleen may enlarge.

More than 60% of untreated people die, usually between the third and fifth day.

Pestis minor

Pestis minor is a mild form of bubonic plague. Its symptoms—swollen lymph nodes, fever, headache, and exhaustion—disappear within a week.

Pneumonic plague

Pneumonic plague is infection of the lungs.

Pneumonic plague symptoms begin abruptly 2 or 3 days after exposure to the bacteria. People have a high fever, chills, a rapid heartbeat, and often a severe headache. Within 24 hours, they develop a cough that brings up clear sputum, which soon becomes flecked with blood. Then the sputum becomes pink or bright red (resembling raspberry syrup) and foamy. Breathing is rapid and labored.

Most untreated people die within 48 hours after symptoms start.

Septicemic plague

Septicemic plague is infection that spreads into the blood. About 40% of people have nausea, vomiting, diarrhea, and abdominal pain.

Eventually, blood clots too much, blocking blood vessels and eventually causing bleeding because clotting factors are used up. This disorder is called disseminated intravascular coagulation. Because blood flow is blocked, gangrene develops in the limbs, which may turn black (hence, the name Black Death).

Without treatment, many organs malfunction, often causing death.

Diagnosis of Plague

  • Examination and culture of samples of blood, sputum, or pus

  • Sometimes other blood tests

To diagnose plague, doctors take samples of blood, sputum, or pus from lymph nodes. Samples are examined under a microscope and sent to a laboratory to grow (culture) bacteria. The blood sample is also tested for antibodies to the bacteria. Tests that rapidly detect the bacteria or its genetic material (DNA), such as polymerase chain reaction (PCR), may be done.

If doctors suspect pneumonic plague, a chest x-ray is taken.

Prevention of Plague

Controlling rodents and using repellents to prevent fleabites can help.

The vaccine against plague is no longer available in the United States.

People who are traveling to locations with a plague outbreak may take an antibiotic such as doxycycline.

After exposure to plague

Doctors monitor people who have had contact with a person who has pneumonic plague. Their temperature is taken every 4 hours for 6 days.

Also, antibiotics are given to prevent the infection from developing. Adults are given doxycycline or ciprofloxacin, and children are given trimethoprim/sulfamethoxazole.

Treatment of Plague

  • Streptomycin or another antibiotic

Treatment begins immediately and reduces the risk of death to less than 5%. Streptomycin is given by injection into a muscle for at least 7 days or until 3 days after temperature has returned to normal. Other antibiotics such as gentamicin, doxycycline, and ciprofloxacin are also effective.

People with pneumonic plague must be isolated so that they do not spread the bacteria through the air—called respiratory isolation. It includes the following:

  • Limiting access to the room

  • Requiring people who work within about 6 1/2 feet (2 meters) of the infected person to wear a mask, eye protection, a gown, and gloves

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