Plague

Plague

Plague is a deadly infectious disease caused by the enterobacteria Yersinia pestis (Pasteurella pestis). Plague is a zoonotic, primarily carried by rodents (most notably rats) and spread to humans via fleas. Plague is notorious throughout history, due to the unrivaled scale of death and devastation it brought. Plague is still endemic in some parts of the world.

Plague

The epidemiological use of the term plague is currently applied to bacterial infections that cause buboes (swelling of the lymph nodes). Plague is often synonymous with bubonic plague.

History
Importance

One of three WHO quarantinable diseases ( cholera, plague & yellow fever) Estimated 200 million deaths recorded

Three

prior pandemics

Justinian 541 AD Black Death 1346 China 1855

Plague Doctor wearing protective clothing
Image: National Library of Medicine

Brief History of Plague

540-590 AD: Justinians pandemic

10,000 deaths per day Fall of the Roman Empire

Blackish areas on the skin caused by subcutaneous hemorrhages. 1/3 of European population died Fall of the feudal system

1346~1400: Black Death pandemic

1665: Great Plague of London 1994 epidemic in Surat, India

Discovery
1894: Hong

Kong epidemic Alexandre Yersin

Gram negative Bacillus Developed antiserum

1896

Transmission

The disease is caused by the gram-negative bacterium Yersinia pestis. It is transmitted from rodent to human by

the bite of an infected flea, direct contact with infected animals or their products, or inhalation of contaminated airborne droplets

Once in the human body, the bacteria multiply in the blood and lymph.
Humans can develop plague through contact with wild animals (sylvatic plague), domestic or semi domestic animals (urban plague), or infected humans.

Bubonic plague is mainly a disease in rodents and fleas (Xenopsylla cheopis). Infection in a human occurs when a person is bitten by a flea that has been infected by biting a rodent that itself has been infected by the bite of a flea carrying the disease. The bacteria multiply inside the flea, sticking together to form a plug that blocks its stomach and causes it to begin to starve. The flea then voraciously bites a host and continues to feed, even though it cannot quell its hunger, and consequently the flea vomits blood tainted with the bacteria back into the bite wound. The bubonic plague bacterium then infects a new victim, and the flea eventually dies from starvation. Serious outbreaks of plague are usually started by other disease outbreaks in rodents, or a rise in the rodent population.

Organisms

Robert B. Crave. Plague. Infectious Diseases, 5th ed. J.B. Lippincott Co. 1994.

Yersinia pestis

Yersinia pestis (formerly Pasteurella pestis) is a Gramnegative rod-shaped bacterium belonging to the family Enterobacteriaceae. It is a facultative anaerobe that can infect humans and other animals. Y. pestis is a rod-shaped facultative anaerobe with bipolar staining (giving it a safety pin appearance).

Organisms

Some of the virulence factors that coincide with its high morbidity and mortality are capsular and envelope proteins, which protect against phagocytosis and foster intracellular growth.

YOPS (yersinal plasmid-encoded outer membrane proteins)

The bacillus also produces coagulase, which clots blood and is involved in clogging the esophagus in fleas and obstructing blood vessels in humans. Other factors that contribute to pathogenicity are endotoxin and a highly potent murine toxin.

Clinical Features

Bubonic Septicemic Pneumonic

Bubonic Plague

Usually from bite of infectious flea Contact with or ingestion of infected animals The bacteria enters the body when a flea bites and contaminates the wound with regurgitated blood, the plague carrying bacteria are passed into the tissue Once in the body, the bacteria can enter the lymphatic system Y. pestis spreads through the lymphatics of the infected human until it reaches a lymph node, where it stimulates severe haemorrhagic inflammation that causes the lymph nodes to expand.

Bubonic Plague
The

expansion of lymph nodes is the cause of the characteristic "bubo" associated with the disease. The incubation period lasts 2 to 8 days, ending abruptly with the onset of fever, chills, headache, nausea, weakness, and tenderness of the bubo. 80-90% of cases Mortality (untreated): 50-60%

Septicemic Plague
Primary

Form Form

Direct inoculation in bloodstream

Development of untreated pneumonic or bubonic plague

Secondary

Septicemic plague

Lymphatics ultimately drain into the bloodstream, so the plague bacteria may enter the blood and travel to almost any part of the body Bubonic plague often progress to massive bacterial growth in the blood termed septicemic plague.

The release of virulence factors causes disseminated intravascular coagulation, subcutaneous hemorrhage, and purpura that may degenerate into necrosis and gangrene. Because of the visible darkening of the skin, the plague has often been called the black death.

Septicemic plague

Cause disseminated intravascular coagulation (DIC) formation of small blood clots inside the blood vessels throughout the body The symptoms include high fever, purple skin patches and continuous vomiting. It is not as famous as the Bubonic Plague simply because it killed in 24 hours nearly 100% of those infected, and simply did not have time to be passed on. Mortality (untreated): 100%

Pneumonic Plague
The

pneumonic plague infects the lungs, and with that infection comes the possibility of person-to-person transmission through respiratory droplets. Pneumonic plague is an infection in the lungs Primary - Y. pestis inhaled Secondary - septicemic form spreads

Pneumonic Plague

Incubation period usually between two and four days, but can be as little as a few hours. The initial symptoms, of headache, weakness, and coughing with hemoptysis, vomiting blood, are indistinguishable from other respiratory illnesses. Without diagnosis and treatment, the infection can be fatal in one to six days; Mortality in untreated cases is approximately 100%

Diagnosis,Treatment, and Prevention

Laboratory diagnosis of plague is by direct microscopic examination, culture of the bacterium, serological tests, the PCR for detection of bacteria in infected fleas. Treatment is with streptomycin, chloramphenicol, or tetracycline, and recovery from the disease gives a good immunity Treated plague has a 9095% survival rate.