6-59
Assessment:
Differential Diagnosis - other forms of pneumonia (both conventional etiologies and other potential
biological weapons: tularemia, staphylococcal enterotoxins), sepsis caused by other gram-negative bacteria,
anthrax.
Plan:
Treatment
Primary: IV gentamicin (1.5 mg/kg every 8 hours), oxygen, intravenous fluids, antipyretics.
Alternative: IV streptomycin, doxycycline, tetracycline, or ciprofloxacin if gentamicin is unavailable.
Primitive: Oral doxycycline or ciprofloxacin if IV therapy is not possible.
Patient Education
General: Pneumonic plague is contagious; caregivers should employ droplet precautions when dealing with
patients. At a minimum, mask either the casualty or the health-care team and close contacts.
Prevention: Contacts exposed to aerosolized plague should take prophylactic oral doxycycline (100 mg
every 12 hours). Oral ciprofloxacin (500 mg every 12 hours) is an alternate. Other fluoroquinolones and
tetracycline are other options.
Follow-up Actions
Evacuation/Consultant Criteria: Evacuate patients promptly, maintaining droplet protection for care providers
and aircrew. Consult Preventive Medicine or infectious disease experts early.
Biological Agents: Smallpox
Introduction: Smallpox is caused by infection with Variola virus. Naturally occurring smallpox has been
globally eradicated since the last case occurred in Somalia in 1977. Authorized stockpiles of virus exist in
only two high-security laboratories. The categorization of smallpox virus as a viable weapon stems from the
fear that belligerent groups may possess clandestine stocks. Moreover, fear exists that other closely related
orthopoxviruses (such as monkeypox or cowpox) might be genetically manipulated to produce variola-like
disease. The incubation period is 7-17 days.
Subjective: Symptoms
Begin abruptly with malaise, fever, rigors, headache, backache, and vomiting.
Objective: Signs
Using Basic Tools: Characteristic rash appears 2-3 days after the onset of symptoms; all lesions progress
synchronously from macules to papules to pustules, and are concentrated on the hands, face and trunk;
fever and mental status changes; complications include viral “sepsis”, hepatic insufficiency, encephalopathy,
skin hemorrhage.
Assessment:
Differential Diagnosis - chickenpox (lesions in various stages of progression and not concentrated on the
trunk), monkeypox, enteroviral exanthems (such as hand-foot-mouth disease).
Plan:
Treatment
Primary: Supportive (oxygen, intravenous fluids, and antipyretics).
Patient Education
General: Smallpox is contagious. Caregivers should employ airborne and contact precautions when dealing