Yersinia pestis infection laboratory findings: Difference between revisions

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{{Yersinia pestis infection}}
{{CMG}}; {{AE}} [[User:YazanDaaboul|Yazan Daaboul]]; [[User:Sergekorjian|Serge Korjian]]


{{Yersinia pestis infection}}
==Overview==
{{CMG}}
Bubonic plague is diagnosed by [[gram stain]] and culture of aspirated material from suppurative [[lymph node]]s.<ref name="pmid24947530">{{cite journal| author=Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL et al.| title=Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of america. | journal=Clin Infect Dis | year= 2014 | volume= 59 | issue= 2 | pages= e10-52 | pmid=24947530 | doi=10.1093/cid/ciu296 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24947530  }} </ref> Collection of blood specimens, [[lymph node]] aspirates from buboes, [[sputum]] samples, and tracheal swabs are needed before the administration of [[antibiotic]]s. Additionally, [[cerebrospinal fluid]] (CSF) collection is required in cases suspected to have meningeal complications of plague.<ref name=Plague1>{{cite book|last=Dennis |first=David |date=2009 |title=Plague |url=http://download.springer.com/static/pdf/583/chp%253A10.1007%252F978-0-387-09843-2_28.pdf?auth66=1406493717_83826f9d10001446712ba861f3e65459&ext=.pdf |location= |publisher=Springer Science+Business Media |page=597 |isbn=DOI 10.1007/978-0-387-09843-2 28 |accessdate=Jul 25 2014 }}</ref>  In the United States, reporting of suspicious cases and sending collected material to specialized labs with expertise in Plague testing and to the State Health Department are mandatory procedures.<ref name=Plague1>{{cite book|last=Dennis |first=David |date=2009 |title=Plague |url=http://download.springer.com/static/pdf/583/chp%253A10.1007%252F978-0-387-09843-2_28.pdf?auth66=1406493717_83826f9d10001446712ba861f3e65459&ext=.pdf |location= |publisher=Springer Science+Business Media |page=597 |isbn=DOI 10.1007/978-0-387-09843-2 28 |accessdate=Jul 25 2014 }}</ref>


==Laboratory Findings==
==Laboratory Findings==
Following a thorough history and physical exam, patients suspected to be infected by the plague require a confirmation of the initial diagnosis. Plague is a quarantinable diseases covered under international regulations.<ref name=WHA>{{cite web |url=http://www.who.int/gb/ebwha/pdf files/WHA58-REC1/english/Resolutions.pdf |title= Plague |date= 2005 |website= World Health Assembly|publisher=WHA|accessdate=Jul 25 2014}}</ref> In the United States, reporting of suspicious cases and sending collected material to specialized labs and to the State Health Department are mandatory procedures.<ref name=Plague1>{{cite book|last=Dennis |first=David |date=2009 |title=Plague |url=http://download.springer.com/static/pdf/583/chp%253A10.1007%252F978-0-387-09843-2_28.pdf?auth66=1406493717_83826f9d10001446712ba861f3e65459&ext=.pdf |location= |publisher=Springer Science+Business Media |page=597 |isbn=DOI 10.1007/978-0-387-09843-2 28 |accessdate=Jul 25 2014 }}</ref>
Following a thorough history and physical exam, patients suspected to be infected by the plague, such as a patient presenting with [[fever]] living in an endemic region, require a confirmation of the initial diagnosis. Plague is a quarantinable disease covered under international regulations.<ref name=WHA>{{cite web |url=http://www.who.int/gb/ebwha/pdf files/WHA58-REC1/english/Resolutions.pdf |title= Plague |date= 2005 |website= World Health Assembly|publisher=WHA|accessdate=Jul 25 2014}}</ref> Patients with bubonic plague suspected to have secondary pneumonic plague should be placed in respiratory isolation until after 48 hours of effective [[antibiotic]] administration.<ref name="pmid24947530">{{cite journal| author=Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL et al.| title=Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of america. | journal=Clin Infect Dis | year= 2014 | volume= 59 | issue= 2 | pages= e10-52 | pmid=24947530 | doi=10.1093/cid/ciu296 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24947530  }} </ref> In the United States, reporting of suspicious cases and sending collected material to specialized labs with expertise in Plague testing and to the State Health Department are mandatory procedures.<ref name=Plague1>{{cite book|last=Dennis |first=David |date=2009 |title=Plague |url=http://download.springer.com/static/pdf/583/chp%253A10.1007%252F978-0-387-09843-2_28.pdf?auth66=1406493717_83826f9d10001446712ba861f3e65459&ext=.pdf |location= |publisher=Springer Science+Business Media |page=597 |isbn=DOI 10.1007/978-0-387-09843-2 28 |accessdate=Jul 25 2014 }}</ref>
 
 
{| border="1" style="border-collapse:collapse; text-align:center;" width=600px cellpadding="5" align="center"
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| bgcolor="#DCDCDC"|According to the "2014 Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue and Soft Tissue Infections", '''The diagnosis of bubonic plague is confirmed only by gram stain and culture of aspirated material from suppurative lymph nodes.'''<ref name="pmid24947530">{{cite journal| author=Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL et al.| title=Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of america. | journal=Clin Infect Dis | year= 2014 | volume= 59 | issue= 2 | pages= e10-52 | pmid=24947530 | doi=10.1093/cid/ciu296 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24947530  }} </ref>
|}
 
 
Other suggested confirmatory tests that have been frequently used include the following<ref name=Plague1>{{cite book|last=Dennis |first=David |date=2009 |title=Plague |url=http://download.springer.com/static/pdf/583/chp%253A10.1007%252F978-0-387-09843-2_28.pdf?auth66=1406493717_83826f9d10001446712ba861f3e65459&ext=.pdf |location= |publisher=Springer Science+Business Media |page=597 |isbn=DOI 10.1007/978-0-387-09843-2 28 |accessdate=Jul 25 2014 }}</ref>:
*A 4x increase in ''Y. pestis'' antibody titer between acute and convalescent phase serum samples
*Lysis of ''Y. pestis'' by unique bacteriophage in culture
 
 
Common laboratory findings may not always be present. They include the following:
 
=====Blood Work-Up=====
*[[Leukoyctosis]] and [[neutrophilia]] with left shift
*[[Thrombocytopenia]]
*Elevated [[D-dimer]]
*Elevated [[transaminase]] and [[bilirubin]] concentrations
*Elevated [[creatinine]]
*[[Hypoglycemia]]
*Elevated ''Y. pestis'' F1 antigen
 
====Urine Work-Up====
*[[Proteinuria]]
 
=====Peripheral Smear=====
*Rod-shaped bacteria on Giemsa stain and "safety pin" (or bipolar) appearance on Wayson stain
*Toxic granulations and Dohle bodies
 
=====Gram Stain=====
*Small [[gram-negative]] coccobacilli
 
=====Culture of Fluids=====
*Positive for ''Y. pestis''


The diagnosis of plague is confirmed only by the following 2 techniques<ref name=Plague1>{{cite book|last=Dennis |first=David |date=2009 |title=Plague |url=http://download.springer.com/static/pdf/583/chp%253A10.1007%252F978-0-387-09843-2_28.pdf?auth66=1406493717_83826f9d10001446712ba861f3e65459&ext=.pdf |location= |publisher=Springer Science+Business Media |page=597 |isbn=DOI 10.1007/978-0-387-09843-2 28 |accessdate=Jul 25 2014 }}</ref>
=====Cerebrospinal Fluid Analysis=====
:
*[[Pleocytosis]] with polymorphonuclear leukocyte predominance
*''Y. pestis'' antibody titers, requiring a 4x increase between the acute and the convalescent phases.
*Limulus test confirms [[endotoxin]]
*Lysis of ''Y. pestis'' by unique bacteriophages in bacterial culture


===Collection of Samples===
==Collection of Samples==
Collection of '''blood specimens''', '''lymph node aspirates''' from buboes, '''sputum samples''', and '''tracheal swabs''' are needed before the administration of antibiotics. Additionally, '''cerebrospinal fluid (CSF) collection''' is required in cases suspected to have meningeal complications of plague.{{cite book|last=Dennis |first=David |date=2009 |title=Plague |url=http://download.springer.com/static/pdf/583/chp%253A10.1007%252F978-0-387-09843-2_28.pdf?auth66=1406493717_83826f9d10001446712ba861f3e65459&ext=.pdf |location= |publisher=Springer Science+Business Media |page=597 |isbn=DOI 10.1007/978-0-387-09843-2 28 |accessdate=Jul 25 2014 }}
Collection of '''blood specimens''', '''lymph node aspirates''' from buboes, '''sputum samples''', and '''tracheal swabs''' are needed before the administration of antibiotics. Additionally, '''cerebrospinal fluid (CSF) collection''' is required in cases suspected to have meningeal complications of plague.<ref name=Plague1>{{cite book|last=Dennis |first=David |date=2009 |title=Plague |url=http://download.springer.com/static/pdf/583/chp%253A10.1007%252F978-0-387-09843-2_28.pdf?auth66=1406493717_83826f9d10001446712ba861f3e65459&ext=.pdf |location= |publisher=Springer Science+Business Media |page=597 |isbn=DOI 10.1007/978-0-387-09843-2 28 |accessdate=Jul 25 2014 }}</ref>


====Blood Samples====
====Blood Samples====
Blood should be sent for analysis, culture, and peripheral smear.
[[Blood]] should be sent for analysis, culture, and peripheral smear.
*If clinically stable, at least 3 samples for culture within 45 minutes should be collected before antibiotic administration.
*If clinically stable, at least 3 samples for culture within 45 minutes should be collected before antibiotic administration.
*Serological diagnosis using passive hemagglutination test (PHA) using ''Y. pestis'' F1 antigen. If samples are retrieved within 3-4 weeks of symptoms onset, serological confirmation is highly sensitive.
*Serological diagnosis using passive hemagglutination test (PHA) using ''Y. pestis'' F1 antigen. If samples are retrieved within 3-4 weeks of symptoms onset, serological confirmation is highly sensitive.


The use of rapid detection tests, such as ELISA and PCR assays to detect F1 antigen are not routinely used yet. However, they may be helpful to confirm cases of suspected plague when gold standard confirmatory tests are not available.<ref name="pmid3492308">{{cite journal| author=Williams JE, Arntzen L, Tyndal GL, Isaäcson M| title=Application of enzyme immunoassays for the confirmation of clinically suspect plague in Namibia, 1982. | journal=Bull World Health Organ | year= 1986 | volume= 64 | issue= 5 | pages= 745-52 | pmid=3492308 | doi= | pmc=PMC2490949 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3492308  }} </ref><ref name="pmid16841399">{{cite journal| author=| title=International meeting on preventing and controlling plague: the old calamity still has a future. | journal=Wkly Epidemiol Rec | year= 2006 | volume= 81 | issue= 28 | pages= 278-84 | pmid=16841399 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16841399  }} </ref><ref name=Plague1>{{cite book|last=Dennis |first=David |date=2009 |title=Plague |url=http://download.springer.com/static/pdf/583/chp%253A10.1007%252F978-0-387-09843-2_28.pdf?auth66=1406493717_83826f9d10001446712ba861f3e65459&ext=.pdf |location= |publisher=Springer Science+Business Media |page=597 |isbn=DOI 10.1007/978-0-387-09843-2 28 |accessdate=Jul 25 2014 }}</ref>
The use of rapid detection tests, such as [[ELISA]] and [[PCR]] assays to detect F1 antigen are not routinely used yet. However, they may be helpful to confirm cases of suspected plague when gold standard confirmatory tests are not available.<ref name="pmid3492308">{{cite journal| author=Williams JE, Arntzen L, Tyndal GL, Isaäcson M| title=Application of enzyme immunoassays for the confirmation of clinically suspect plague in Namibia, 1982. | journal=Bull World Health Organ | year= 1986 | volume= 64 | issue= 5 | pages= 745-52 | pmid=3492308 | doi= | pmc=PMC2490949 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3492308  }} </ref><ref name="pmid16841399">{{cite journal| author=| title=International meeting on preventing and controlling plague: the old calamity still has a future. | journal=Wkly Epidemiol Rec | year= 2006 | volume= 81 | issue= 28 | pages= 278-84 | pmid=16841399 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16841399  }} </ref><ref name=Plague1>{{cite book|last=Dennis |first=David |date=2009 |title=Plague |url=http://download.springer.com/static/pdf/583/chp%253A10.1007%252F978-0-387-09843-2_28.pdf?auth66=1406493717_83826f9d10001446712ba861f3e65459&ext=.pdf |location= |publisher=Springer Science+Business Media |page=597 |isbn=DOI 10.1007/978-0-387-09843-2 28 |accessdate=Jul 25 2014 }}</ref>
 


====Lymph Node Aspiration====
====Lymph Node Aspiration====
Bubo aspiration, using a small sterile syringe containing sterile saline, is performed by insertion of the needle into the central part of the bubo. If original aspiration fails, injection of the sterile saline inside the syringe may be performed and then aspirated. The aspirate is then used as follows<ref name=Plague1>{{cite book|last=Dennis |first=David |date=2009 |title=Plague |url=http://download.springer.com/static/pdf/583/chp%253A10.1007%252F978-0-387-09843-2_28.pdf?auth66=1406493717_83826f9d10001446712ba861f3e65459&ext=.pdf |location= |publisher=Springer Science+Business Media |page=597 |isbn=DOI 10.1007/978-0-387-09843-2 28 |accessdate=Jul 25 2014 }}</ref>
[[Bubo]] aspiration, using a small sterile syringe containing 1 mL sterile saline, is performed by insertion of the needle into the central part of the bubo. If original aspiration fails, injection of the sterile saline inside the syringe may be performed and then aspirated. The aspirate is then used as follows<ref name=Plague1>{{cite book|last=Dennis |first=David |date=2009 |title=Plague |url=http://download.springer.com/static/pdf/583/chp%253A10.1007%252F978-0-387-09843-2_28.pdf?auth66=1406493717_83826f9d10001446712ba861f3e65459&ext=.pdf |location= |publisher=Springer Science+Business Media |page=597 |isbn=DOI 10.1007/978-0-387-09843-2 28 |accessdate=Jul 25 2014 }}</ref>
:
:
*2 slide preparations for routine staining, using Giemsa (or Wayson) method and for gram stain.
*2 slide preparations for routine staining, using Giemsa (or Wayson) method and for gram stain
*2 slide preparations for direct fluorescent antibody (FA) testing
*2 slide preparations for direct fluorescent antibody (FA) testing


Aspirate should also be used for culture using sheep blood agar, brain-heart infusion (BHI) broth, and MacConkey agar.
Aspirate should also be used for culture using sheep [[blood agar]], brain-heart infusion (BHI) broth, and [[MacConkey agar]].
====Other Specimens====
====Other Specimens====
All aspirates and specimens from CSF, tracheal swab, and sputum also need to be tested using gram stain, Giemsa stain, and FA testing.{<ref name=Plague1>{{cite book|last=Dennis |first=David |date=2009 |title=Plague |url=http://download.springer.com/static/pdf/583/chp%253A10.1007%252F978-0-387-09843-2_28.pdf?auth66=1406493717_83826f9d10001446712ba861f3e65459&ext=.pdf |location= |publisher=Springer Science+Business Media |page=597 |isbn=DOI 10.1007/978-0-387-09843-2 28 |accessdate=Jul 25 2014 }}</ref>
All aspirates and specimens from [[CSF]], [[trachea|tracheal]] swab, and [[sputum]] also need to be tested using [[gram stain]], [[Giemsa stain]], and FA testing.<ref name=Plague1>{{cite book|last=Dennis |first=David |date=2009 |title=Plague |url=http://download.springer.com/static/pdf/583/chp%253A10.1007%252F978-0-387-09843-2_28.pdf?auth66=1406493717_83826f9d10001446712ba861f3e65459&ext=.pdf |location= |publisher=Springer Science+Business Media |page=597 |isbn=DOI 10.1007/978-0-387-09843-2 28 |accessdate=Jul 25 2014 }}</ref>
 
==Gallery==
<gallery>
Image:Plague40.jpeg| Yersinia pestis bacteria cultured on a xylose-lysine-deoxycholate (XLD) agar medium 24hrs (10x mag). <SMALL> <SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Plague41.jpeg| Yersinia pestis bacteria cultured on a sheep blood agar (SBA) medium 72hrs (10x mag). <SMALL> <SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Plague42.jpeg| Yersinia pestis bacteria cultured on a sheep blood agar (SBA) medium 24hrs (10x mag). <SMALL> <SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Plague43.jpeg| Yersinia pestis bacteria cultured on sheep blood agar (SBA) medium 120hrs. <SMALL> <SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Plague44.jpeg| Yersinia pestis bacteria cultured on a sheep blood agar (SBA) medium, for a 120hrs (20x mag). <SMALL> <SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Plague45.jpeg| Yersinia pestis bacteria cultured on a sheep blood agar (SBA) medium 120hrs (5x mag). <SMALL> <SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Plague46.jpeg| Yersinia pestis bacteria cultured on a sheep blood agar (SBA) medium 120hrs (10x mag).<SMALL> <SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Plague47.jpeg|Yersinia pestis bacteria cultured on a MacConkey agar (MAC) medium 48hrs (10x mag). <SMALL> <SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Plague48.jpeg|Yersinia pestis bacteria cultured on a MacConkey agar (MAC) medium 24hrs (10x mag).<SMALL> <SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Plague49.jpeg|Yersinia pestis bacteria cultured on a MacConkey agar (MAC) medium 24 hrs (10x mag). <SMALL> <SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL>
 
Image:Plague50.jpeg|Yersinia pestis bacteria cultured on a cefsulodin-Irgasan-novobiocin (CIN) agar medium 48hrs (20x mag).<SMALL> <SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Plague51.jpeg|Yersinia pestis bacteria on a chocolate agar plate 120hrs.<SMALL> <SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Plague52.jpeg| Yersinia pestis bacteria cultured on a blood agar plate (BAP) 24hrs (10x). <SMALL> <SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Plague53.jpeg| Yersinia pestis bacteria cultured on a blood agar plate (BAP) 24hrs (10x mag). <SMALL> <SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Plague54.jpeg|Yersinia pestis bacteria cultured on sheep blood agar (SBA) 48hrs (10x). <SMALL> <SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Plague55.jpeg| Yersinia pestis bacteria, cultured on MacConkey agar (MAC) medium 72hrs (10x mag). <SMALL> <SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Plague56.jpeg| Gram-negative Yersinia pestis bacteria, cultured on sheep blood agar (SBA) medium 24hrs (10x mag). <SMALL> <SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Plague10.jpg| Photomicrograph depicting a blood smear that revealed the presence of Gram-negative Yersinia pestis plague bacteria.<SMALL> <SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
 
Image: Bubonic plague16.jpeg| Histopathologic changes in a lymph node tissue sample in a case of fatal human plague. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Bubonic plague10.jpeg| Gram-negative Yersinia pestis bacteria, grown on a medium of chocolate agar 24hrs. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Bubonic plague09.jpeg| Gram-negative Yersinia pestis bacteria, grown on SBA 72hrs. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Bubonic plague08.jpeg| Gram-negative Yersinia pestis bacteria, grown on SBA 72hrs. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Bubonic plague06.jpeg| Gram-negative Yersinia pestis bacteria, grown on chocolate agar 72hrs. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
 
 
 
 
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Latest revision as of 00:46, 30 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Yazan Daaboul; Serge Korjian

Overview

Bubonic plague is diagnosed by gram stain and culture of aspirated material from suppurative lymph nodes.[1] Collection of blood specimens, lymph node aspirates from buboes, sputum samples, and tracheal swabs are needed before the administration of antibiotics. Additionally, cerebrospinal fluid (CSF) collection is required in cases suspected to have meningeal complications of plague.[2] In the United States, reporting of suspicious cases and sending collected material to specialized labs with expertise in Plague testing and to the State Health Department are mandatory procedures.[2]

Laboratory Findings

Following a thorough history and physical exam, patients suspected to be infected by the plague, such as a patient presenting with fever living in an endemic region, require a confirmation of the initial diagnosis. Plague is a quarantinable disease covered under international regulations.[3] Patients with bubonic plague suspected to have secondary pneumonic plague should be placed in respiratory isolation until after 48 hours of effective antibiotic administration.[1] In the United States, reporting of suspicious cases and sending collected material to specialized labs with expertise in Plague testing and to the State Health Department are mandatory procedures.[2]


According to the "2014 Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue and Soft Tissue Infections", The diagnosis of bubonic plague is confirmed only by gram stain and culture of aspirated material from suppurative lymph nodes.[1]


Other suggested confirmatory tests that have been frequently used include the following[2]:

  • A 4x increase in Y. pestis antibody titer between acute and convalescent phase serum samples
  • Lysis of Y. pestis by unique bacteriophage in culture


Common laboratory findings may not always be present. They include the following:

Blood Work-Up

Urine Work-Up

Peripheral Smear
  • Rod-shaped bacteria on Giemsa stain and "safety pin" (or bipolar) appearance on Wayson stain
  • Toxic granulations and Dohle bodies
Gram Stain
Culture of Fluids
  • Positive for Y. pestis
Cerebrospinal Fluid Analysis

Collection of Samples

Collection of blood specimens, lymph node aspirates from buboes, sputum samples, and tracheal swabs are needed before the administration of antibiotics. Additionally, cerebrospinal fluid (CSF) collection is required in cases suspected to have meningeal complications of plague.[2]

Blood Samples

Blood should be sent for analysis, culture, and peripheral smear.

  • If clinically stable, at least 3 samples for culture within 45 minutes should be collected before antibiotic administration.
  • Serological diagnosis using passive hemagglutination test (PHA) using Y. pestis F1 antigen. If samples are retrieved within 3-4 weeks of symptoms onset, serological confirmation is highly sensitive.

The use of rapid detection tests, such as ELISA and PCR assays to detect F1 antigen are not routinely used yet. However, they may be helpful to confirm cases of suspected plague when gold standard confirmatory tests are not available.[4][5][2]

Lymph Node Aspiration

Bubo aspiration, using a small sterile syringe containing 1 mL sterile saline, is performed by insertion of the needle into the central part of the bubo. If original aspiration fails, injection of the sterile saline inside the syringe may be performed and then aspirated. The aspirate is then used as follows[2]

  • 2 slide preparations for routine staining, using Giemsa (or Wayson) method and for gram stain
  • 2 slide preparations for direct fluorescent antibody (FA) testing

Aspirate should also be used for culture using sheep blood agar, brain-heart infusion (BHI) broth, and MacConkey agar.

Other Specimens

All aspirates and specimens from CSF, tracheal swab, and sputum also need to be tested using gram stain, Giemsa stain, and FA testing.[2]

Gallery


References

  1. ↑ 1.0 1.1 1.2 Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL; et al. (2014). "Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of america". Clin Infect Dis. 59 (2): e10–52. doi:10.1093/cid/ciu296. PMID 24947530.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Dennis, David (2009). Plague (PDF). Springer Science+Business Media. p. 597. ISBN DOI 10.1007/978-0-387-09843-2 28 Check |isbn= value: invalid character (help). Retrieved Jul 25 2014. Check date values in: |accessdate= (help)
  3. ↑ files/WHA58-REC1/english/Resolutions.pdf "Plague" Check |url= value (help) (PDF). World Health Assembly. WHA. 2005. Retrieved Jul 25 2014. Check date values in: |accessdate= (help)
  4. ↑ Williams JE, Arntzen L, Tyndal GL, Isaäcson M (1986). "Application of enzyme immunoassays for the confirmation of clinically suspect plague in Namibia, 1982". Bull World Health Organ. 64 (5): 745–52. PMC 2490949. PMID 3492308.
  5. ↑ "International meeting on preventing and controlling plague: the old calamity still has a future". Wkly Epidemiol Rec. 81 (28): 278–84. 2006. PMID 16841399.
  6. ↑ 6.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.09 6.10 6.11 6.12 6.13 6.14 6.15 6.16 6.17 6.18 6.19 6.20 6.21 6.22 "Public Health Image Library (PHIL), Centers for Disease Control and Prevention".

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