terrorism and biologic agents
TRANSCRIPT
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Terrorism and Biologic Agents
Biological Agents and Terrorism
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Terrorism and Biologic Agents
Objectives
• Learn how to perform an assessment of a biologic agent such as anthrax in a terrorism situation.
• Discuss the history of anthrax as a biologic weapon
• Recognize various disease presentations of anthrax.
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Terrorism and Biologic Agents
Objectives
• Discuss the pathogenesis of anthrax • Recognize naturally occurring anthrax
presentations versus weaponized anthrax
• Learn how to medically manage anthrax infections.
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Terrorism and Biologic Agents
Biologic Agent Case• Winter in the Midwest• Typical Year
– Many complaints of a runny nose
– Many complaints of a cough– Many complaints of a tactile
fever
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Terrorism and Biologic Agents
Biologic Agent Case• A 40 y/o police officer presents with a
fever and muscle aches. He is pale, has a temperature of 102°F. His physical exam and labs are unremarkable so he is discharged and given flu instructions. He says his partner is also ill.
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Terrorism and Biologic Agents
Biologic Agent Case• Later, a 35 y/o female clerk also presents
complaining of myalgias, shaking chills, and vomiting. She is pale, and has a temperature of 102.4°F. Her physical exam is non-focal, she improves with antipyretics and the patient is sent home with viral syndrome instructions.
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Terrorism and Biologic Agents
Biologic Agent CaseThe next day several more patients present with fever, chills and myalgias.
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Terrorism and Biologic Agents
Biologic Agent Case• The 40 yo policeman
returns 3 days later because he is feeling much worse and is short of breath.
• This is the chest x-ray that was obtained
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Terrorism and Biologic Agents
Biologic Agent Case• A mother brings in her
adolescent son for a strange black scab/rash that started out as a small papule but formed a black painless eschar over the past 5 days.
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Terrorism and Biologic Agents
Biologic Agent Case• Another family brings in
their adolescent daughter for evaluation of a “bad infection”
• Surrounding facial edema is uncomfortable/painful
• The developing eschar is relatively painless
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Terrorism and Biologic Agents
Biologic Agent Case• The ED calls your office
informing you of the admission of the 35 yo female for fever, mental status changes, meningismus, pneumonia, hypoxia, respiratory distress and shock.
• After LP, the gram-stain was described as gram positive rods with spores.
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Terrorism and Biologic Agents
What is the Agent?
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Terrorism and Biologic Agents
Anthrax (Bacillus anthracis)• Where is it found naturally? • History as a biological weapon• How does it cause disease?• What types of disease does it cause
(clinical effects)?• Treatment
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Terrorism and Biologic Agents
Naturally Occurring Anthrax• Caused by a gram-positive spore
forming rod• Spore if very hardy can survive for
decades in the soil• Important veterinary disease as
herbivores may be prone to the disease if they feed in ‘anthrax zones’
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Terrorism and Biologic Agents
Naturally Occurring Anthrax• Endemic cases are usually present as
cutaneous disease (95%; <1-20% mortality)
• Contracted by contact of abraded skin with products of infected cattle, sheep and goats
• Products include hides, hair, wool, bone and meat.
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Terrorism and Biologic Agents
Naturally Occurring Anthrax
• Inhalational anthrax (wool sorter’s disease) from inhalation of spores from textile and slaughterhouse workers (<5% cases; 45-89% mortality)
• Gastrointestinal Anthrax is very rare and occurs from consuming infected meat (<5%; >50% mortality)
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Terrorism and Biologic Agents
Weaponized Anthrax• WHO estimates that 50 Kg dispersed
along a 2 Km line upwind of a city of 500,000 could cause 125,000 infections and 95,000 deaths
However• May be difficult to weaponize into small
enough particles• ID50 of 8,000 to 10,000 spores
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Terrorism and Biologic Agents
Weaponized Anthrax History
Sverdlovsk, Russia, 1979• Accidental release from biological
weapons facility due to a faulty filter• Plume swept over city by the wind• ≥77 cases, 66 deaths• Last person became ill 43 days after
initial release
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Terrorism and Biologic Agents
Weaponized Anthrax History• October 2001 letter
associated Anthrax outbreak• 22 cases
– 11 Inhalational (5 deaths)– 11 Cutaneous (No deaths)
• Very different distribution compared to naturally occurring disease
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Terrorism and Biologic Agents
Anthrax Disease Process• Anthrax has at least three proteins
which play a role in virulence• A-B model of toxicity• Edema factor (EF), Lethal factor (LF)
and Protective antigen (PA)• EF and LF need PA to get into the cell
to cause damage
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Terrorism and Biologic Agents
Anthrax Disease Process
• EF + PA creates edema toxin• LF + PA creates lethal toxin• The toxins cause lymphatic necrosis
which leads to the release of Bacillus anthracis
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Anthrax Disease Process
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Terrorism and Biologic Agents
Cutaneous Anthrax• Progression of painless lesions
Papule/macule – pruritic
Vesicle/bulla – clear or serosanguinous
Ulcer – nonpitting, gelatinous edema
Eschar – black, depressed, rarely scars,
24-48 hrs
days
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Terrorism and Biologic Agents
Cutaneous Anthrax
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Terrorism and Biologic Agents
Cutaneous Anthrax
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Terrorism and Biologic Agents
Inhalational Anthrax Clinical Features
• Initially starts with a non-specific flu-like illness and then progresses to:– Respiratory Distress– Shock
• May see a widened mediastinum on x-ray
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Anthrax – Hemorrhagic Meningitis
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Terrorism and Biologic Agents
Gastrointestinal Anthrax• Nausea, anorexia, vomiting, fever• Progresses to severe abdominal pain
and bloody emesis and diarrhea• Ascites may develop on day 2 - 4• Death 2 to 5 days after onset of
symptoms• Very difficult to diagnose
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Terrorism and Biologic Agents
Treatment
Cutaneous Anthrax • without systemic signs, extensive edema or
lesions located on head and neck. • Initial recommended treatment:
– Doxycycline or Ciprofloxacin PO for 60 days
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Terrorism and Biologic Agents
TreatmentCutaneous Anthrax • with systemic signs,
extensive edema or lesions on the head and neck.
• Initial recommended treatment:– Doxycycline or Ciprofloxacin IV– May switch to PO when clinically appropriate
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Terrorism and Biologic Agents
Treatment
Inhalational, GI, Sepsis• Initial recommended treatment:
– Doxycycline or Ciprofloxacin IV– May switch to PO when clinically
appropriate
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Terrorism and Biologic Agents
Questions?
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Terrorism and Biologic Agents
Question #1The antibiotic of choice among the following for
treating an anthrax infection is:
a. Cefuroxime b. Doxycylcinec. Penicillind. Pentamidinee. Trimethoprim-sulfamethoxazole
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Terrorism and Biologic Agents
Question #2The most common naturally occurring form of
anthrax is:
a. Cutaneousb. Gastrointestinalc. Inhalationald. Oculare. Mediastinal
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Terrorism and Biologic Agents
Question #3
Which of the following is an isolated protein necessary for the virulence of anthrax?
a. Edema toxinb. Lethal toxinc. Lymphatic factord. Necrosis factore. Protective antigen
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Terrorism and Biologic Agents
Question #4
The order of development of the classic cutaneous anthrax lesion is:
a. Bullae, vesicle, ulcer, escharb. Papule, vesicle, ulcer, eschar c. Vesicle, bullae, eschar, ulcerd. Ulcer, vesicle, bullae, eschar
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Terrorism and Biologic Agents
Question #5After low-level germination at the site of entry to
the body, anthrax may be taken up by:
a. Basophilsb. Eosinophilsc. Lymphocytesd. Macrophagese. Neutrophils
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Terrorism and Biologic Agents
This completes the current presentation.