Plague A20.9

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!

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

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

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

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.

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

Tularemia, lymphogranuloma inguinale.

Isolation of the patient.

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.

Lethality of bubonic plague untreated 50%, treated 10%.

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

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

1. Spyrou MA et al.(2019) Phylogeography of the second plague pandemic revealed through analysis of historical Yersinia pestis genomes.Nat Commun 10:4470.

2. Yang R (2017) Plague: recognition, treatment, and prevention. J Clin Microbiol 56:e01519-17.