Plague A20.9

Author: Prof. Dr. med. Peter Altmeyer

Last updated on: 15.06.2022

Synonym(s)

Black death; Black Death; bubonic plague; Pestilentia; Pestis

Definition
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Historically important anthropozoonosis occurring in epidemics. A distinction is made between bubonic plague (90% of cases), pestilence, pneumonic plague or abortive plague (Spyrou MA et al. 2019). Note: obligation to report!

Pathogen
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Yersinia (Pasteurella) pestis. Reservoir: rodents (especially rats) and their fleas.

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Occurrence/Epidemiology
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Currently limited endemic areas in Central Africa, Madagascar, Central Asia, Russia and America.

Etiopathogenesis
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Transmission of the pathogen by fleas (bubonic plague), contact with infected animals or by droplet infection from person to person (pneumonic plague).

Clinical features
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Incubation period: 1-6 days.

Bubonic plague (bubonic plague): flea bite, development of an inflammatory papule; painful regional lymphadenitis. Fever, toxic CNS symptoms (e.g. delirium). In bacteremia: petechiae, ecchymosis, consumption coagulopathy. Also: erythema, vesicles and pustules.
Pulmonary plague: severe clinical picture with dyspnoea, cyanosis, haemoptoe. Without chemotherapy lethal course.
Plague sepsis: fatal complication in the final stage of bubonic plague or pneumonic plague, even after small or undetectable bubons.
Abortive plague: Mostly single bubo, slight fever. Purulent melting and healing.

Diagnosis
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Only by cultivation of the pathogen (special laboratory, blood culture).

Differential diagnosis
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Tularemia, lymphogranuloma inguinale.

Therapy
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Isolation of the patient.

Internal therapy
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Rapid initiation of effective antibiotic therapy (within 24 hours after the first symptoms appear). The first choice are streptomycin (e.g. Strepto-Fatol) 30 mg/kg bw/day i.m. in 2-3 doses or gentamicin (e.g. Refobacin) 3-5 mg/kg bw/day i.v. or i.m. spread over 3 doses over 5-10 days.

Alternatively: Erythromycin (erythrocin i.v.), adults 2 g/day i.v. in 4 cycles, children 20-30 mg/kg bw/day i.v. in 4 cycles. Alternatively: Doxycycline (e.g. Supracycline) initial 200 mg, then 100 mg p.o. twice a day for 10-14 days.

Progression/forecast
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Lethality of bubonic plague untreated 50%, treated 10%.

Prophylaxis
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Safe protection of contact persons (post-exposure prophylaxis) with Doxycycline 2 times/day 100 mg p.o.

Note(s)
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Bioterrorism with plague bacteria has been reported in the USA (Yang R 2017).

Literature
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Spyrou MA et al.(2019) Phylogeography of the second plague pandemic revealed through analysis of historical Yersinia pestis genomes.Nat Commun 10:4470.
Yang R (2017) Plague: recognition, treatment, and prevention. J Clin Microbiol 56:e01519-17.