Threat agents

CDC category agents are those biologic threat agents thought to be of major public health concern. Extensive coverage of these and other pathogens of concern in bioterrorism can be found elsewhere (Sidell et al., 1997). Data concerning clinical incubation periods, transmission characteristics, and infection control procedures for selected agents of bioterrorism are provided in Table 12.4. Syndromic differential diagnoses for select clinical presentations are detailed in Table 12.5.

Table 12.4 Infection control issues for selected agents of bioterrorism

Disease

Incubation

Person-to-person

Infection control

period

transmission

practices

Inhalation of

2-43* days

No

Standard

anthrax

Botulism

12-72 hours

No

Standard

Primary pneumonic

1-6 days

Yes

Droplet

plague

Smallpox

7-17 days

Yes

Contact and

air-borne

Tularemia

1-14 days

No

Standard

Viral hemorrhagic

2-21 days

Yes

Contact and

fevers

air-borne

Viral encephalitides

1-14 days

No

Standard

Q fever

2-14 days

No

Standard

Brucelloses

5-60 days

No

Standard

Glanders

10-14 days

No

Standard

*Based on limited data from human outbreaks; experimental animal data support clinical latency periods of up to 100 days

Source: Artenstein (2003), reproduced with permission.

*Based on limited data from human outbreaks; experimental animal data support clinical latency periods of up to 100 days

Source: Artenstein (2003), reproduced with permission.

Table 12.5 Syndromic differential diagnoses of selected bioterrorism agents

Clinical presentation

Disease

Differential diagnosis

Non-specific flu-like symptoms with nausea, emesis; cough with or without chest discomfort, without coryza or rhinorrhea, leading to abrupt onset of respiratory distress with or without shock; mental status changes, with chest radiograph abnormalities (wide mediastinum, infiltrates, pleural effusions)

Inhalational anthrax

Bacterial mediastinitis, tularemia, Q fever, psittacosis, Legionnaires' disease, influenza, Pneumocystis carinii pneumonia, ruptured aortic aneurysm, superior vena cava syndrome, histoplasmosis, coccidioidomycosis, sarcoidosis

Pruritic, painless papule, leading to vesicle(s), leading to ulcer, leading to edematous black eschar with or without massive local edema and regional adenopathy and fever, evolving over 3-7 days

Cutaneous anthrax

Recluse spider bite, plague, staphyloccal lesion, atypical Lyme disease, orf, glanders, tularemia, rat-bite fever, ecthyma gangrenosum, rickettsial pox, atypical mycobacteria, diphtheria

Rapidly progressive respiratory illness with cough, fever, rigors, dyspnea, chest pain, hemoptysis; possible gastrointestinal symptoms; lung consolidation with or without shock

Primary pneumonic plague

Severe community-acquired bacterial or viral pneumonia, inhalational anthrax, inhalational tularemia, pulmonary infarct, pulmonary hemorrhage

Sepsis, disseminated intravascular coagulation, purpura, acral gangrene

Septicemic plague

Meningococcemia, Gram-negative, streptococcal, pneumococcal or staphylococcal bacteremia with shock; overwhelming postsplenectomy sepsis, acute leukemia, Rocky Mountain spotted fever, hemorrhagic smallpox, hemorrhagic varicella (in immunocompromised patients)

(Continued) S

GO PO

Table 12.5 (Continued)

Clinical presentation

Disease

Differential diagnosis

Fever, malaise, prostration, headache, myalgias followed by development of synchronous, progressive papular leading to vesicular and then pustular rash on face, mucous membranes (extremities more than the trunk); rash may become generalized, with a hemorrhagic component and system toxicity Non-specific flu-like illness with pleuropneumonitis; bronchiolitis with or without hilar lymphadenopathy; variable progression to respiratory failure

Acute onset of afebrile, symmetric, descending flaccid paralysis that begins in bulbar muscles; dilated pupils, diplopia or blurred vision; dysphagia; dysarthria; ptosis; dry mucous membranes leading to airway obstruction with respiratory muscle paralysis; clear sensorium and absence of sensory changes Acute-onset fevers, malaise, prostration, myalgias, headache, gastrointestinal symptoms, mucosal hemorrhage, altered vascular permeability, disseminated intravascular coagulation, hypotension leading to shock with or without hepatitis and neurologic findings

Smallpox

Inhalational tularemia Botulism

Viral hemorrhagic fever

Varicella, drug eruption, Stevens-Johnson syndrome, measles, secondary syphilis, erythema multiforme, severe acne, meningococcemia, monkeypox, generalized vaccinia, insect bites, Coxsackie virus infection, vaccine reaction

Inhalational anthrax, pneumonic plague, influenza, mycoplasma pneumonia, Legionnaires' disease, Q fever, bacterial pneumonia

Myasthenia gravis, brain-stem cerebrovascular accident, polio, Guillain-Barrè syndrome variant, tick paralysis, chemical intoxication

Malaria, meningococcemia, leptospirosis, rickettsial infection, typhoid fever, borrelioses, fulminant hepatitis, hemorrhagic smallpox, acute leukemia, thrombotic thrombocytopenic purpura, hemolytic uremic syndrome, systemic lupus erythematosus

Source: Artenstein (2003), reproduced with permission.

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