Last  updated 11/02/01

Prepared by LTC Michael Roy, Dept. of Medicine, USUHS

Bioterrorism Reference Table
Anthrax Botulinum Plague Smallpox Tularemia
Agent Bacillus anthracis Clostridium botulinum Yersinia pestis Variola major

(Orthopox virus)

 Francisella tularensis
Unique features Spores can survive in soil up to 40 yrs; causes black, coal-like skin lesions with animal contact Toxin, types A-G; irreversibly binds to neuromuscular junction preventing Ach release Very easily spread person-to-person. Need to wear mask if treating potential cases. Non-spore forming GNR. Easily spread person-to-person or from contaminated clothing Hardy non-spore-forming GNR, can survive for weeks; highly infectious; zoonotic
Likely route of Dissemination as weapon Aerosol; coincident cutaneous exposure possible Aerosol, or food or water contamination Aerosol Aerosol Aerosol; contamination of food or water also possible
Incubation Period Avg 1-6 days

range up to 8 weeks

 Hours to 5 days Avg 2-4 days, range 1-6 days Avg 12-14 days, range 7-19 days Avg 3-5 days, range 1-14 days
Clinical Presentation fever, cough, dyspnea, headache, vomiting, chills, weakness; followed by hemorrhagic thoracic lymphadenitis and mediastinitis (CXR: widened mediastinum), hemorrhagic meningitis, shock Nausea, vomiting, cranial nerve palsies (ptosis, diplopia, dysphagia, dysphonia), flaccid paralysis. No fever. May decrease secretions (as opposed to nerve agents) Fever, chills, headache, malaise, followed by cough, hemoptysis, dyspnea, stridor, cyanosis, and death for pneumonic plague (CXR: bilateral patchy infiltrates) malaise, fever, rigors, vomiting, headache, backache. Skin lesions 2-3 days later, progress from macules to papules, then to pustular vesicles Initial nonspecific febrile illness; then pleuropneumonitis over days to weeks. (CXR: pneumonic process, mediastinal lymphadenopathy or pleural effusion)
Diagnosis ELISA and PCR at national reference labs—contact Dept of Health Clinical; ELISA and PCR in development Gram, Wright, Giemsa or Wayson stain of blood, sputum, CSF, or lymph node aspirates Virions on EM; light microscopy, Guarnieri bodies (aggregations of variola virus particles) on LM Culture possible but difficult; gram stain or DFA of sputum, exudates, or tissue; serology confirmatory later
Mortality Rate Up to 90% unless antibiotics given before symptoms <5% w/proper support; 50-60% without Nearly 100% for untreated pneumonic 30% 2% with rx; 5-15% overall, but up to 30-60% w/o treatment
Treatment Ciprofloxacin; other quinolones, amoxicillin, and doxycycline may be effective Anti-toxin; intubation and mechanical ventilation Doxycycline, quinolones, aminoglycosides, or chloramphenicol Quarantine, supportive rx, consider antiviral or post-exposure vaccination Quinolones, macrolides, aminoglycosides,

doxycycline, or

chloramphenicol
Vaccine? Yes, for military Toxoid & human antibodies can provide protection In development Yes Yes, for lab workers; under FDA review

 

Other potential biologic agents to consider: (N.B., the initial symptoms of most are non-specific and difficult to differentiate; symptoms also may vary according to route of exposure)

Pulmonary syndromes

1. Brucella

2. Q fever (Coxiella burnetti)

3. Glanders (Burkholder mallei)

4. Melioidosis (Burkholder pseudomallei)

5. Ricin

6. Mycotoxins (dermatologic symptoms usually precede pulmonary symptoms)

Other

1. Viral hemorrhagic fevers

2. Staphylococcal enterotoxin B (gastrointestinal symptoms often predominate)

3. Viral encephalitides (neurologic symptoms often predominate)

 

Ten Steps in the Management of Biological Casualties:

(paraphrased from USAMRIID’s Medical Management Of Biological Casualties Handbook)

1. Have a high index of suspicion—early treatment is often essential to survival

2. Protect yourself—take appropriate vaccines, use mask if suspected agent is transmitted person-to-person

3. Perform rapid clinical assessment, with attention to neurologic, dermatologic, and pulmonary findings

4. Appropriate decontamination

5. Confirm a diagnosis

6. Consider early empiric treatment

7. Maintain infection control

8. Alert appropriate authorities (e.g., Dept of Health or military public health officials)

9. Assist epidemiologic investigation

10. Keep your knowledge up to date on potential threats and their likely clinical presentations.

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