Bioterrorism Agents Plague

Lesson 8
Scenarios and Questions

Overview

Developing scenario
Questions to review knowledge
Additional questions for laboratorians and
veterinarians

Plague Scenario Question 1

Physician in Hartford, Connecticut

35yo male, no underlying
Fever, chills, malaise, myalgias x 3 days
Productive cough, watery mucoid sputum,
chest pain x 1 day
What would you review to rule out other
diseases?

Plague Scenario Question 1

What would you review to rule out other
diseases?
A. Mediastinum on x-ray
B. Progression of disease
C. Presence of influenza
D. A and C
E. A, B and C

Plague Scenario Question 1

What would you review to rule out other
diseases?
E. A, B and C

Mediastinum on x-ray
Progression of disease
Presence of influenza

Plague Scenario Question 2

Patient deteriorating rapidly

No widening of mediastinum
No influenza in community
You suspect plague
What specimens will you collect for
laboratory workup?

Plague Scenario Question 2

What specimens will you collect for
laboratory workup?
A.
B.
C.
D.
E.

Pharyngeal swabs
Tracheal wash or aspirates
Sputum specimens
Serology
All of the above

Plague Scenario Question 2

What specimens will you collect for
laboratory workup?
E. All of the above

Pharyngeal swabs
Tracheal wash or aspirates
Sputum specimens
Serology

Plague Scenario Question 3

Laboratory initial report
Small, gram-negative, bipolar-staining, plump
rods in single, short chains
Catalase positive
Oxidase and urease negative
Unable to rule out Y. pestis

You suspect plague

What is your next step?

Plague Scenario Question 3

What is your next step?
A.
B.
C.
D.

Shut down the hospital

Refer to hospitals reference laboratory
Call public health
All of the above

Plague Scenario Question 3

What is your next step?
C. Call public health

Plague Scenario Question 4

Youve contacted your hospitals infection
control practitioner
What should your infection control
practitioner recommend to you?

Plague Scenario Question 4

What should your infection control
practitioner recommend to you?
A.
B.
C.
D.

Patient on respiratory precautions

Close contacts on prophylaxis
Names of those within 6 feet of patient
A and C

Plague Scenario Question 4

What should your infection control
practitioner recommend to you?
D. A and C

Patient on respiratory precautions

Names of those within 6 feet of patient

Plague Scenario Question 5

Asked to obtain travel history
If its naturally-acquired, where would he
have traveled?

Plague Scenario Question 5

If its naturally-acquired, where would he
have traveled?
A.
B.
C.
D.

Australia
Canada
Western United States
Northeast United States

Plague Scenario Question 5

If its naturally-acquired, where would he
have traveled?
C. Western United States

Plague Scenario Question 6

Consulted with public health
All specimens they need have been
collected
What treatment regimen would you
consider?

Plague Scenario Question 6

What treatment regimen would you
consider?
A.
B.
C.
D.

Gentamicin
Ampicilin
Tetracycline
Bactrim

Plague Scenario Question 6

What treatment regimen would you
consider?
A. Gentamicin

Plague Scenario Question 7

Plague confirmed by state public health

Six other suspect cases
Cases clustered in your area

What will public health ask you to do to help

manage this outbreak?

Plague Scenario Question 7

What will public health ask you to do to help
manage this outbreak?
A.
B.
C.
D.

Close down hospital

Call the media
Conduct chart review
Everyone in building on prophylaxis

Plague Scenario Question 7

What will public health ask you to do to help
manage this outbreak?
C. Conduct chart review

Plague Scenario Question 8

12 people in ER
Compatible symptoms
All attended the hockey game
What procedure should be in place in the
Emergency Room?

Plague Scenario Question 8

What procedure should be in place in the
Emergency Room?
A.
B.
C.
D.

All patients into respiratory isolation

Shut down the ER
Call public health
A and C

Plague Scenario Question 8

What procedure should be in place in the
Emergency Room?
D. A and C

All symptomatic patients into isolation

Call public health

Plague Scenario Question 9

1,459 confirmed, probable and suspect

Pneumonic plague
Associated with ice hockey game
Your hospital has 200 cases
Mass Casualty Treatment Protocol

What is one of the medications you will use

for your adult patients?

Plague Scenario Question 9

What is one of the medications you will use
for your adult patients?
A.
B.
C.

Gentamicin 5mg/kg IM or IV
Doxycycline 100mg PO BID
Doxycycline 100mg IV BID or 200mg
IV
D. Ciprofloxacin 400mg IV BID

Plague Scenario Question 9

What is one of the medications you will use
for your adult patients?
B. Doxycycline 100mg PO BID

Questions for Laboratorians

Plague Scenario Laboratory

Question 1
Microbiologist at hospital in Hartford,
Connecticut
Specimens pharyngeal swabs, sputum,
serology
Patient presenting with pneumonia
What presentation would you expect on a
Gram stain if this was plague?

Plague Scenario Laboratory

Question 1
What presentation would you expect on a
Gram stain if this was plague?
A. Gram-positive bacillus, singly and chains
B. Faintly staining, very tiny Gram-negative
coccobacillus, mostly single cells
C. Plump, Gram-negative rod
D. Faintly staining, small Gram-negative
coccobacillus, fine sand

Plague Scenario Laboratory

Question 1
What presentation would you expect on a
Gram stain if this was plague?
C. Plump, Gram-negative rod

Plague Scenario Laboratory

Question 2
Growth plates prepared
Sheep blood agar
What presentation would you expect to see
after 48 hours?

Plague Scenario Laboratory

Question 2
What presentation would you expect to see after 48
hours?
A. Slow growing, pinpoint, gray-white to opaque
colonies, fried egg
B. Growing poorly, 1-2mm, gray-white, non-hemolytic
C. Slow growing, pinpoint, smooth, entire border,
translucent, non-hemolytic
D. Rapidly growing, non-pigmented, dry ground
glass surface, flat or slightly convex, irregular
edges with Medusa head

Plague Scenario Laboratory

Question 2
What presentation would you expect to see
after 48 hours?
A. Slow growing, pinpoint, gray-white to
opaque colonies, fried egg

Plague Scenario Laboratory

Question 3
Suspicious of Y. pestis
Other, more definitive tests
What other characteristics would you expect
to see?

Plague Scenario Laboratory

Question 3
What other characteristics would you expect
to see?
A. Hemolysis None, Catalase (+), NonMotile
B. Oxidase (-), Catalase (+), Urea (-),
Indole (-)
C. Oxidase (-), Catalase Weak (+), lactamase (+), Satellite (-), Urease (-)
D. Oxidase (+), Urease (+), Satellite (-)

Plague Scenario Laboratory

Question 3
What other characteristics would you expect
to see?
B. Oxidase (-), Catalase (+), Urea (-),
Indole (-)

Questions for Veterinarians

Plague Scenario Veterinarian

Question 1

Vet in small-animal practice

Hartford, Connecticut
Near ice hockey arena
Domestic feline
Owner suspects pneumonic plague

What signs and symptoms would you expect

to see?

Plague Scenario Veterinarian

Question 1
What signs and symptoms would you expect to
see?
A. Fever, respiratory difficulty, excitement and
depression, vomiting, bloody diarrhea
B. Depression, lymphadenopathy, abcesses,
oral or lingual ulceration, anorexia
C. Rapidly progressing illness, fever, cough
bloody sputum

Plague Scenario Veterinarian

Question 1
What signs and symptoms would you expect
to see?
C. Rapidly progressing illness, fever, cough
bloody sputum

Plague Scenario Veterinarian

Question 2
Domestic feline
Signs and symptoms seem to match
plague
What kind of treatment would you begin on
this cat?

Plague Scenario Veterinarian

Question 2
What kind of treatment would you begin on
this cat?
A.
B.
C.

Gentamicin
Penicillin
Fluorquinolones

Plague Scenario Veterinarian

Question 2
What kind of treatment would you begin on
this cat?
A. Gentamicin

Plague Scenario Veterinarian

Question 3
You suspect plague
Lab specimens
Pharyngeal swab
Serology

Lab results: Unable to rule out Y. pestis

What is your next step?

Plague Scenario Veterinarian

Question 3
What is your next step?
A.
B.
C.

Send it to private reference laboratory

Call public health
Shut down your practice

Plague Scenario Veterinarian

Question 3
What is your next step?
B. Call public health