chapter 109

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.

Chapter 109Chapter 109

Potential Weapons of Potential Weapons of Biologic, Radiologic, and Chemical Biologic, Radiologic, and Chemical

TerrorismTerrorism

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. 2

Potential Weapons of TerrorismPotential Weapons of Terrorism BacteriaBacteria VirusesViruses BiotoxinsBiotoxins Chemical weapons Chemical weapons

Nerve agents and mustard gasNerve agents and mustard gas Radiologic weaponsRadiologic weapons


Bacteria and VirusesBacteria and Viruses AnthraxAnthrax

Bacillus anthracisBacillus anthracis • Aerobic gram-positive bacteriumAerobic gram-positive bacterium

Dormant form viable for decadesDormant form viable for decades Inhalational, cutaneous, gastrointestinal Inhalational, cutaneous, gastrointestinal Enters the body via the skin or mucous Enters the body via the skin or mucous

membranes of the respiratory tractmembranes of the respiratory tract Not transmitted person to person Not transmitted person to person


Inhalational AnthraxInhalational Anthrax Anthrax spores deposit in alveolar spaceAnthrax spores deposit in alveolar space Even with treatment, mortality can be highEven with treatment, mortality can be high Clinical latency 2 days-4 weeksClinical latency 2 days-4 weeks

Mature bacilli release toxinsMature bacilli release toxins• Hemorrhage, edema, and necrosisHemorrhage, edema, and necrosis• If toxins reach critical level, antibiotics cannot prevent deathIf toxins reach critical level, antibiotics cannot prevent death

Initial symptomsInitial symptoms Fever, cough, malaise, weaknessFever, cough, malaise, weakness

Second stage (2-3 days later)Second stage (2-3 days later) Sudden increase in fever, severe respiratory distress, Sudden increase in fever, severe respiratory distress,

septicemia, hemorrhagic meningitis, and shocksepticemia, hemorrhagic meningitis, and shock


Cutaneous AnthraxCutaneous Anthrax Symptoms 1-7 days after exposure to sporesSymptoms 1-7 days after exposure to spores

Broken skin most vulnerableBroken skin most vulnerable Injury can develop anywhere spores landInjury can develop anywhere spores land Initial lesion Initial lesion –– small papule or vesicle associated with local small papule or vesicle associated with local

itchingitching• 2 days – lesion enlarges into painless ulcer with necrotic core2 days – lesion enlarges into painless ulcer with necrotic core• 7-10 days after symptoms – black eschar forms, then dries, 7-10 days after symptoms – black eschar forms, then dries,

loosens, and sloughs off by days 12-14loosens, and sloughs off by days 12-14 In most cases lesions resolve without complications In most cases lesions resolve without complications

or scarringor scarring Treatment is usually successful, but 20% die without Treatment is usually successful, but 20% die without

antibiotic treatmentantibiotic treatment


Treatment of Anthrax Infection Treatment of Anthrax Infection RespiratoryRespiratory

IV ciprofloxacin IV ciprofloxacin IV doxycycline IV doxycycline

CutaneousCutaneous Oral ciprofloxacin Oral ciprofloxacin Oral doxycyclineOral doxycycline


Pre-Exposure VaccinationPre-Exposure Vaccination BioThrax (formerly known as Anthrax Vaccine BioThrax (formerly known as Anthrax Vaccine

Adsorbed, or AVA)Adsorbed, or AVA) Licensed for use in U.S.Licensed for use in U.S. Inactivated cell-free preparationInactivated cell-free preparation 3 subQ injections 2 weeks apart, then at 6, 12, 3 subQ injections 2 weeks apart, then at 6, 12,

and 18 monthsand 18 months Persons at high risk should be vaccinatedPersons at high risk should be vaccinated

• Military personnel, those who handle animal products Military personnel, those who handle animal products from anthrax-endemic areas, including veterinarians, lab from anthrax-endemic areas, including veterinarians, lab workers, othersworkers, others


Postexposure ProphylaxisPostexposure Prophylaxis Oral antibiotics + anthrax vaccineOral antibiotics + anthrax vaccine Vaccine at 0, 2, and 4 weeksVaccine at 0, 2, and 4 weeks BioThrax not currently licensed for BioThrax not currently licensed for

postexposurepostexposure


Francisella tularensisFrancisella tularensis (Tularemia) (Tularemia) “Rabbit Fever” and “Deer Fly Fever”“Rabbit Fever” and “Deer Fly Fever”

Potentially fatalPotentially fatal Skin, mucous membranes, GI tract, or lungsSkin, mucous membranes, GI tract, or lungs Acute flu-like symptoms initiallyAcute flu-like symptoms initially Pneumonia and pleuritis can developPneumonia and pleuritis can develop TreatmentTreatment

IM streptomycin, gentamicinIM streptomycin, gentamicin Mass outbreak – oral doxycycline or ciprofloxacinMass outbreak – oral doxycycline or ciprofloxacin


Pneumonic PlaguePneumonic Plague Transmitted person to personTransmitted person to person Acquired by inhaling aerosolized Acquired by inhaling aerosolized Yersinia Yersinia

pestispestis With no treatment, rapidly progresses to With no treatment, rapidly progresses to

respiratory failure and death respiratory failure and death Treatment is streptomycin (IM) and Treatment is streptomycin (IM) and

gentamicin (IM or IV)gentamicin (IM or IV)


SmallpoxSmallpox No proven treatmentNo proven treatment Highly contagious; fatality rate 30% Highly contagious; fatality rate 30% ACAM2000 approved vaccineACAM2000 approved vaccine Imvamune (in clinical trials)Imvamune (in clinical trials) Vaccine produces high level of immunity for 5 Vaccine produces high level of immunity for 5

to 10 years (before exposure or within a few to 10 years (before exposure or within a few days of exposure)days of exposure)

Pathogenesis and clinical manifestationsPathogenesis and clinical manifestations TransmissionTransmission


Smallpox Vaccine Smallpox Vaccine Adverse effectsAdverse effects

Mild effectsMild effects• Local inflammation, along with swelling and tenderness in Local inflammation, along with swelling and tenderness in

regional lymph nodesregional lymph nodes• Transient symptoms (fever, headache, muscle aches, fatigue)Transient symptoms (fever, headache, muscle aches, fatigue)

Moderate to severeModerate to severe• Eczema vaccinatum, generalized vaccinia, progressive Eczema vaccinatum, generalized vaccinia, progressive

vaccinia, postvaccinial encephalitis, fetal vaccinia, possible vaccinia, postvaccinial encephalitis, fetal vaccinia, possible cardiac effectscardiac effects

Who should not be vaccinated?Who should not be vaccinated? Persons with eczema, atopic dermatitis, immunodeficiency, Persons with eczema, atopic dermatitis, immunodeficiency,

pregnancypregnancy Persons living with someone elsePersons living with someone else


BiotoxinsBiotoxins Botulinum toxinBotulinum toxin

Clostridium botulinumClostridium botulinum Blocks release of acetylcholine from cholinergic Blocks release of acetylcholine from cholinergic

neuronsneurons With no treatment, rapidly progresses to paralysis With no treatment, rapidly progresses to paralysis

and respiratory failure and death and respiratory failure and death Classic symptoms – double vision, blurred vision, Classic symptoms – double vision, blurred vision,

drooping eyelids, slurred speech, dry mouth, drooping eyelids, slurred speech, dry mouth, dysphagia, muscle weakness, descending flaccid dysphagia, muscle weakness, descending flaccid paralysisparalysis


Botulinum ToxinBotulinum Toxin TreatmentTreatment

Prolonged supportive careProlonged supportive care• Fluid/nutritional supportFluid/nutritional support• Mechanical ventilationMechanical ventilation

Immediate infusion of botulinum antitoxinImmediate infusion of botulinum antitoxin


RicinRicin Toxin present in castor beansToxin present in castor beans

Extraction from the “mash” when beans are Extraction from the “mash” when beans are processed to make castor oilprocessed to make castor oil

Powder, pellet, mist, or dissolved in water or a Powder, pellet, mist, or dissolved in water or a weak acidweak acid

Inhibits protein synthesisInhibits protein synthesis Treatment is purely supportiveTreatment is purely supportive

No antidote for ricinNo antidote for ricin Vaccine in developmentVaccine in development


Ricin: Clinical ManifestationsRicin: Clinical Manifestations InhalationInhalation

Few hours – coughing, chest tightness, difficulty breathing, Few hours – coughing, chest tightness, difficulty breathing, nausea, muscle aches nausea, muscle aches

Later – severely inflamed/edematous airway; cyanosis and Later – severely inflamed/edematous airway; cyanosis and death can followdeath can follow

Ingestion Ingestion Intestinal and gastric hemorrhage, vomiting, diarrhea; then Intestinal and gastric hemorrhage, vomiting, diarrhea; then

liver, spleen, kidneys may fail; death within 10-12 days of liver, spleen, kidneys may fail; death within 10-12 days of ingestioningestion

InjectionInjection Severe symptoms and death; impractical route for terrorismSevere symptoms and death; impractical route for terrorism


Chemical WeaponsChemical Weapons Nerve agentsNerve agents

Produce a state of cholinergic crisis, characterized Produce a state of cholinergic crisis, characterized by excessive muscarinic stimulation and by excessive muscarinic stimulation and depolarizing neuromuscular blockade depolarizing neuromuscular blockade

Treatment – mechanical ventilation, atropine, and Treatment – mechanical ventilation, atropine, and diazepam diazepam


Chemical WeaponsChemical Weapons Sulfur mustard (mustard gas)Sulfur mustard (mustard gas)

Alkylating agent and vesicantAlkylating agent and vesicant Can be vaporized into air or released into water Can be vaporized into air or released into water

supplysupply Injuries severe, but fatality rate is lowInjuries severe, but fatality rate is low During WWI – killed less than 5% of victimsDuring WWI – killed less than 5% of victims


Radiologic WeaponsRadiologic Weapons Nuclear bombsNuclear bombs

Immediate and delayed impactImmediate and delayed impact Nuclear power plant attackNuclear power plant attack

Radiation exposure in areaRadiation exposure in area Dirty bombs (radiologic dispersion devices)Dirty bombs (radiologic dispersion devices)

Radioactive material formulated into powder or Radioactive material formulated into powder or pelletspellets


Drugs for Radiation EmergenciesDrugs for Radiation Emergencies Potassium iodidePotassium iodide

Prompt treatment necessaryPrompt treatment necessary Penetrate zinc trisodium and penetrate Penetrate zinc trisodium and penetrate

calcium trisodiumcalcium trisodium Treatment within 24 hours most effectiveTreatment within 24 hours most effective

Prussian blue (Radiogardase)Prussian blue (Radiogardase)

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