Acute transmissible zoonotic disease, characterized by a serous-haemorrhagic

in the place of pathogen reproduction, manifested by severe intoxication,

affection of lymphatic tissue, damage of internal organs and development of sepsis-like state.
It refers to particularly dangerous (quarantine) infections.

Plague

Enterobacteria
Nonmotile, ovoid shaped with rounded ends;
No spores, no flagella, has

a delicate capsule;
Gram – negative;
Obligate intracellular parasite;
Facultative anaerobe;
Grows slowly at T-37 ͦC
on the simple nutrient mediums;
8. Sensitivity: to heating, boiling, disinfection, antibiotics (streptomycin, tetracycline, chloramphenicol);
9. Resistancy: drying, freezing,
low temperature

V-Ag, W-Ag (protection from phagocytosis);

11. Produces exotoxin, factors of aggression:

- coagulase,
- hyaluronidase,
- hemolysin,
- fibrinolysin

12. Endotoxin liberating at distraction has tropicity to the
vascular endothelium and blood cells;

promote pathogen dissemination, increased vessel permeability, thromboformation and disorde of hemocirculation

Causative agent :

red rats);

- carnivorous mammals (cats, foxes, dogs);
- patient with pneumonic form of plague;
3. Vector: rat flea, flea of human dwellings;
4. Mechanism of transmission: - vector-borne (via flea bite);
- alimentary;
- contact (processing of
contaminated meat);
- aerogenic (contact with patients
with pneumonic plague);
5. Susceptibility: high and general;
6. Risk groups: veterinarians, breeders, hunters, farmers, dog
trainers, deratizators, plumbers, workers in landfills;
7. Immunity: relative, specific, can be repeated cases of infection

the ret ̓s body with normal T (not more than

37°).
It gets infection before a death of the animal in the period of bacteremia (when Т
becomes febrile).
3. During the bloodsucking Yersinia passes in prestomach of flea, accumulates and forms a clot (like the gelatinous mass). When flea tries to suck the blood clot is block the blood flow to the stomach, promoting the regurgitation of bacteria into the wound of bite.
Leaving the corpse, flea jumps on the other rodent (animal) or man, infecting them
via the bite.

implementation)
Penetration – usually without local changes, but sometimes - primary

affect;
Regional distribution:
- from the site of inoculation through the lymphatic vessels
(no lymphangitis) reaches the regional lymph nodes (lymphodenitis);
- in the lymph nodes Yersinia enters the mononuclear cells but not
destroyed due to V, W-Ag (incomplete phagocytosis);
- in the lymph nodes bacteria multiply, causing serous-hemorrhagic
inflammation within 2 to 6 days;
- lymph node increases, swells, forming conglomerate (bubo);
Bacteriemia - bubo is necrotized and Yersinia goes into the blood, liberating endotoxin and causing intoxication;
Parenchymal diffusion - Yersinia spreads to other organs and lymph nodes via the blood, causes hemorrhagic inflammation of them, and forms secondary buboes or secondary pulmonary plague (when reaches the lungs);
Immunological (recovery) - with a favorable prognosis, or
terminal (death) - an unfavorable outcome

- primary affect;

- in the lymph nodes Yersinia

enters the mononuclear cells but
not destroyed due to V, W,-Ag (incomplete phagocytosis);
- in the lymph nodes, the bacteria multiply, causing serous
hemorrhagic inflammation within 2 to 6 days;
- lymph node increases, swells, forming conglomerate (bubo);

Regional distribution:

from the site of inoculation through the lymphatic vessels
(no lymphangitis) reaches the regional lymph nodes (lymphadenitis);

- bubonic (70

– 80%);
- cutaneous-bubonic;

2) Pneumonic (5 – 10%): - primary;
- secondary;

3) Septicemic (15 – 20%): - primary;
- secondary;
4) Plague meningitis;

5) Other forms (abortive);

6) Unverificated plague;

- in epidemics or septic form – 1-2 days;

- in vaccinated people – 8-10 days;

2. Initial period: - onset is acute or sudden;

- expressed intoxication:

* chills, weakness,
* rapid rise of body temperature to 39-40ºC,
* pain in the lumbar area and sacrum,
* pain in muscles, joints,
* severe headache, dizziness,
* expressed thirst, repeated vomiting
(sometimes bloody);

* delirium, hallucinations (1-st day of the disease),
* disorded

gait, coordination, disturbed speech,
* tremor of tongue

- hood-symptom:
* hyperemic, edematous face, neck and shoulders,
* injected sclera, on the face – expression of suffering “facies pestica”;

- catarrhal syndrome:
* thickened coated tongue with white fir (chalk-like);
* can be enlarged tonsils, covered with white pseudomembranes,
* hemorrhagic enanthema on the soft palate (sometimes);

- cardiovascular syndrome:
* severe tachycardia, arrhythmia,
* hypotension,
* dull heart sounds, increased heart sizes;

tachypnea, dyspnea;
hepatosplenomegaly;
oliguria;

Cutaneous form (3-4%)

(with formation of primary affect – ulcer in place of penetration)

Local lesions:

Spot;
Papule;
Vesicle;
Pustule;
Ulcer;
Scar

General changes:

1. Regional lymphadenitis – bubo-formation;
2. Intoxication

mm, - with clear
edges
Papule

red, painful,
in D=1-1,5 cm,
elevating

over the
skin,
- with clear edges

Vesicle

- with serous
content, painful,
- soft,
- surrounded by a rim
of hyperemia
and moderate edema

2- 4 hours

4-6 hours

2-4 hours

Rapid formation of a primary affect !!!

- surrounded by a rim of hyperemia and moderate edema
Ulcer

yellow bottom, covered
with dark scab,
painful, dense,
surrounded by a zone of
hyperemia and moderate
edema,
heals slowly,
surrounded by secondary
vesicles - phlyctenas

Scar

4-6 hours

2-3 weeks

of a single (but m. b. several) inflamed lymph node

in diameter more then 2 cm.
1. Plague bubo is often single (in 95%), D = 1 - 10 cm;
2. Localization:
- inguinal region – 60-70%,
- axillary region – 15-20%,
(more dangerous due to development
of secondary pneumonia),
- cervical area – 5%
(dangerous due to the proximity to the brain);

3. On the periphery of bubo may be secondary
elements with hemorrhagic content and Yersinia
- plague phlyctenas;

- sclerosis (for 15-20 days)
- rupture;

5. After opening the bubo the patient’s condition
improves.

6. A little bubo is more painful, but bigger bubo is better
due to stronger barrier function;

7. Bubo is formed within 3-4 days, on the 8-th day – may
suppurate;

8. Heals for 3-4 weeks.

primary regional infection,
when regional lymph nodes are

involved;
1) dense, sharply painful,
2) immobile,
3) connected with surrounding tissues (periadenitis),
4) has fuzzy edges,
5) skin over the bubo is hot, tense, painful, hyperemic
with cyanotic shade,
6) in the center of bubo - fluctuation, peripheraly – edema,
7) no lymphangitis;

2. Secondary bubo - is developed in the phase of dissemination, can be involved lymph nodes of different remote localization;
1) dense, painful,
2) mobile,
3) nonconnected with surrounding tissues (no periadenitis),
4) has clear edges,
5) skin over the bubo is hot, tense, painful, hyperemic,
6) no lymphangitis,
7) size is smaller

Headache and chills,
4. Nausea, vomiting, abdominal pain, diarrhea,

anorexia,
5. Tachycardia, tachypnea, hypotension,
6. Whitish tongue,
7. Redness and swelling of the face,
8. Pain at movements;

CBC: leukocytosis, shift of formula to the left,
increased ESR.

Without treatment patient dies within 3-5 days (40-90%)

Primary septicemic form: (1-3%)
1. Lasts 1-3 days;
2. Short incubation (4-6 hours – 1-2 days);
3. Acute or sudden onset;
4. Chills, fast rising of Тº (40-41ºC);
5. General weakness, myalgia, arthralgia, headache;
6. Nausea, vomiting (bloody);
7. Agitation, confusion, delirium, disarthria;
8. Impaired consciousness (stupor – coma);
9. FE: total cyanosis, edema of the face;
10. Cardio-vascular syndrome: tachycardia, hypotension, muffled
heart sounds, tachypnea;
11. Hepatosplenomegaly;
12. Oligo-, anuria;
13. CBC: leukocytosis, shift to the left, increased ESR;

Prognosis for untreated patient – death within 48 hours.

reflexes)

- hemorrhagic syndrome: epistaxis, hematemesis and bloody
diarrhea,

hematuria, bleeding at the injection sites

infectious-toxic shock

- cardiovascular failure

Secondary septicemic plague:

1. Develops as a complication of other forms;
2. Has more severe clinical manifestation;
3. Hemorrhagic syndrome, secondary lesions and
buboes dominate in the clinic;
4. Patient dies in the first hours or days of illness;
5. Diagnosis to be confirmed retrospectively.

2. Incubation – 1-2 days;
3. Initial period: - duration

1-2 days,
- sudden onset,
- rise body- ТºC, Intoxication syndrome
- chills, vomiting,
- severe headache,

- cutting pains in the chest,
- shortness of breath, tachypnea,
- cough is dry (1-st day),
later - with liquid transparent foamy
bloody sputum,
- tachycardia,
- delirium,
- at auscultation – scanty data: hard breathing, rales (seldom).

Respiratory syndrome

increased:
- hectic

ТºC, hyperemic face, injected sclera (“rabbit eyes’’),
- delirium, agitation,
- coated enlarged tongue,

- respiratory syndrome:
- shortness of breath, tachypnea, wheezes,
- bloody sputum,
- short sounds at percussion of lungs,
- week breathing, moist rales,

- muffled heart sounds, irregular pulse,
hypotension,
- pethechial rush, massive hemorrhages
in skin,
- puffy face, total cyanosis,

X-ray reveals numerous small
inflammatory pneumonic foci with
a tendency to merge

consciousness,
- CV failure, ARF,
Hemorrhagic syndrome, DIS-syndrome,
Total cyanosis, fear of

death,
Buboes do not have time to form,
Patient dies on the 3-5 day, often due to pulmonary
edema and ITS


Secondary pneumonic form:
a complication of bubonic
plague, similar to primary
pneumonic plague.

Prognosis: serious, usually - unfavorable

in the 1-st days of illness.
Tachypnea is always

detected at all patients but
does not correspond to the process in the lungs.
In the beginning of the disease rare wheezing,
breathing is moderately hard. X-ray: focal, segmental, lobar pneumonia.
On the 2-d day – moist rales, shortening of
percussion sound over the lungs.
5. Cough with mucus, bloody sputum.
6. Pain in the chest on the inhale and pleuropneumonia.
7. Early development of ITS.
Hepatosplenomegaly.
Lymphadenopathy (paratracheal, parabronchial).
Death in 18 hours.

form - activation of secondary microflora,

- formation of phlegmon,
- development of secondary
septicemia;
2. Pneumonic form: - hemorrhagic pulmonary edema,
- acute respiratory failure,
- ITS;
3. Septicemic form: - ITS,
- acute heart failure,
- meningitis,
- bleeding;

The mortality rate:
- bubonic form: untreated - 70%, in treatment - 10-20%,
- pneumonic form: untreated - 100%, treated - 30 to 50%,
- septicemic form: - untreated - 100%

- stay in the natural plague focus (visit in country,

unfavorable
for plague),
- contact with source of plague (sick human, animal),
- using of meat of infected animals,
- hunting, skinning rodents or infected animals;

2. Clinical:
- sudden onset,
- hyperthermia, severe intoxication, toxic encephalopathy,
- whitish tongue (as chalk),
- dense, sharply painful, nonmotile bubo with a red-cyanotic skin
over it,
- hemorrhagic syndrome,
- progressive pneumonia;

3. In CBC: leukocytosis, shift formula to the left, increased ESR,

4. GUT: microhematuria, proteinuria, oliguria

1. Material for the study:
- punctate of

bubo, contents of vesicles, pustules,
- smear-imprint of ulcers, smear from the oropharynx,
- sputum, blood, urine, vomiting mass;

2. Bacterioscopy (result in 1-2 h) - ovoid gram-negative bacillus,
painted bipolar;
3. Rapid test (result in 15 min) – IFR;

4. Bacteriological examination: growing of
material on Martin‘s or Hottinger agar;
5. Biological test on animals
(mice and Guinea pigs);

6. Serological methods:
- RPHA; - RIHA; - RN; - ELISA;
7. PCR

department;

2. In cases of suspected plague immediate beginning of

etiotropic
treatment before etiological confirmation (more favorable
prognosis);

3. Firs-choice drug - streptomycin – 1g × 4 t/d i/m or i/v
till the 5-th day of normal temperature (on an average
7-14 days);

At absence of ARF can be taken gentamycin - 0,002 g/kg × 3 t/d i/m within 10 days;

5. Second-choice drug – doxycycline 0,1 g × 2 t/d i/m or per os
within 10 days;

6. At the resistance - chloramphenicol - 0,5-1 g × 4 t/d

Detoxication (dextrose, reopoliglyucin, saline solutions),
- diuretics,
- cardiac glycosides,
- glucocorticoids,
- vitamins;

Symptomatic treatment: antipyretics, analgetics;

NB!!! Surgical treatment (opening buboes) is contraindicated due to possible dissemination of Yersinia (action of promoted factors);

Patient can be discharged from the department in
4 (bubonic form) - 6 (pneumonic form) weeks from the moment of recovery at presence of 3 negative results of bacteriologic investigation of bubo- punctate, sputum, feces and pharyngeal swab;