Learning objectives
  •  Realize that all frontline medical care providers should be familiar with bioterrorism concepts such as preparedness, recognition and reporting to healthcare authorities
  • Initiate management of a critically ill simulated patient with unknown diagnosis
  • Create a differential diagnosis which includes pneumonic plague
  • Manage pneumonic plague
Patient history and exam The patient is a 39-year-old who presents to the healthcare facility with fever, shortness of breath and a productive cough with bloody sputum. She was in good health until just several hours ago.
She also experiences headache, nausea, and vomiting. The patient is a manager in a high end retail store and lives in a middle class apartment complex with her husband. She does not have a pet. Past medical history shows no other hospitalizations. She has never had surgery. She denies tobacco. She denies ethanol use. She has no known drug allergies. She is at this healthcare facility with her husband and sister who are also coughing although they are not febrile and do not appear ill.
Exam shows an uncomfortable patient. She is wearing a cap with the logo from a local sporting team. A little bit of blood is seen exiting her mouth after one of her coughs. Temperature is 103.1°.
Pulmonary exam shows significant rales and rhonchi. Pulse is 110.
Respirations are 28. Social history shows that she attended a major sporting event 3 days ago.
Labs CBC-wbc=19,000, hgb=14.5 hct=42 platelets=174,000
Simulation parameters
  • Temperature=103.1°F. Pulse=110. R=28. BP=105/75
  • A little bit of simulated blood should be placed at the corner of the patient’s mouth to demonstrate hemoptysis
  • Pulmonary exam reveals significant rales and rhonchi throughout the exam.
Expected actions by participants
  • Realize that the patient is extremely ill.
  • With physical exam, identify lungs as the likely source of infection.
  • Order appropriate diagnostic studies such as Complete Blood Count, microscopy of sputum and sputum culture
  • Order Chest X-ray.
  • Construct a differential diagnosis which includes transmissible pulmonary infections such as pneumonic plague.
  • Take a social history which includes the patient’s avid support of a local sports team and realize the patient could have been exposed to pathogens in the arena.
  • Identify the fact that the patient’s husband and sister are also coughing.
  • Realize the potential risk of pneumonic plague transmission to healthcare workers and initiate respiratory precautions.
  • Provide supportive care including oxygen.
  • Initiate appropriate antibiotic therapy.
  • Contact appropriate health officials
  • High-fidelity patient simulator.
  • Actor- patients husband.
  • Actress- patient’s sister.
  • Actress voice of the simulator.
  • Cap from a local athletic team to place on the simulator.
  • A streak of blood for the corner of the patient’s mouth to simulate hemoptysis.
  • Chest X-ray consistent with pneumonic plague (such X-rays can be found on Google images).
  • Resuscitative equipment such as oxygen by mask or endotracheal tube at the discretion of the simulation director.
Additional literature Inglesby TV, Dennis DT, Henderson DA (2000) Plague as a biological weapon. JAMA 283: 2281-2290.
Kman NE, Nelson RN (2008) Infectious agents of Bioterrorism: a review for emergency physicians. Emerg Med Clin N Am 26: 517-547.
Competencies addressed
  • Patient care.
  • Medical knowledge.
  • Systems-based practice.
Debriefing points
  • This is a difficult diagnosis. An important purpose of a medical simulation experience is to present and discuss rare diagnosis so that learners and clinicians can become familiarized. If the participants have initiated antibiotic therapy and respiratory precautions, they may well have performed valuable medical service in a real similar situation.
  • Plague infection as a result of a terrorist attack would be different than natural infection. Bubonic plague is the most common form of plague seen in the natural world whereas pneumonic plague would be the most likely seen in a terrorist attack.
  • A terrorism attack with plaque would most likely occur via an aerosol of Yersinia Pestis.
  • The possible diagnoses of plague may at first be overlooked given clinical similarity to other pneumonias.
  • Symptoms would occur 1 to 6 days after exposure with death following soon after the onset of symptoms if the exposed patients are untreated; the fatality rate for patients is high when treatment is delayed for greater than 24 hours.
  • The first signs of illness are expected to be fever with cough and dyspnea. The production of bloody, watery or purulent sputum along with gastrointestinal symptoms may also occur.
  • Chest x-ray findings in pneumonic plague are variable but bilateral infiltrates or consolidation is likely.
  • Symptomatic patients should be placed in respiratory isolation.
  • The first clinical suspension of plague must lead to notification of health departments and local or state officials. Many hospitals may not have facilities to perform diagnostic testing for plague and may need outside assistance from specialized laboratories for such study.
  • Antibiotic options for pneumonic plague include streptomycin, which is used infrequently United States; only modest supplies are available. Gentamycin is a off label second choice. Tetracycline and Doxycycline are also FDA approved for plague. Other medications which have been used to treat plague include tetracyclines, and fluoroquinolones and chloramphenicol.
  • A seven-day course of doxycycline is recommended for postexposure prophylaxis.
Table 1: Bioterrorism - pneumonic plague.
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