Hospital Practice

ISSN: 2154-8331 (Print) 2377-1003 (Online) Journal homepage: http://www.tandfonline.com/loi/ihop20

Possible Pneumonic Plague R. Russell Martin To cite this article: R. Russell Martin (1979) Possible Pneumonic Plague, Hospital Practice, 14:12, 24-26, DOI: 10.1080/21548331.1979.11707656 To link to this article: http://dx.doi.org/10.1080/21548331.1979.11707656

Published online: 06 Jul 2016.

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Date: 12 August 2017, At: 14:26

ncAR'

(Sterile Ticarcillin Disodium)

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for lntramuscular or lntravenous Use For complete prescnbing Information. consul! oll1cial package insert. ACTIONS: Tlcarcillln is bactencldal: Il is not absorbed or ally, there· lore, il must be admmlstered lntravenously or mtramuscularly. INDICATIONS: TICAR (Ticarclllin Dlsodlum) is lndicated lor the !rearment olthe lollowing Infections Bacterlal septicemlat Skln and soiHissue lnrectlonst Acule and chronic respiratory tractlnlectionst:l: . tcaused by susceptible suams or Pseudomonas aeruomosa. Proteus species tboth mdole·poslllve and mdole-negatrve) and Eschertchia co/1. . t tThough cllmcal lmprovemenl has been shawn, bacteno· rootcal cures cannat be expecled m patients wlth chronlc respnatory dlsease or cystic liblos1s 1 . Genllourinary tract infections (complicated and uncomphcated) due to susceptible strains al Pseudomonas aeruomosa.Pro· reus species !bath Indole-positive and Indole-negative). Escherichia coli. Enrerollacrer and Srreprococcus raeca11s (enterococcus). Tlcarcillln ls also lndlcated in the ueatment al the tollowina Infections due lo susceptible anaerobie bacteria: 111 Bacterlal septicemia . !2) Lower resplratory tract Infections such as empyema. anaerobie pneumonitrs and luna abscess . !3)1ntra·abdomlnal infections such as pelitonlusand lntra-abdoml· nal abscess ltypically resultlng from anaerobrc orgamsms reSI· dent in the normal gastrorntestrnaltract). (4) lnlectlons or the lemale pelvis and genital tract such as endo· metrills. pelvlc lnllammatory disease. pelvlc abscess and salplngitis. 15) Skin and sol Hl ssue Infections . Allhough Ticarcillin ls primarily indlcaled agamst Gram-negative Infections. us m v11ro activlly against Gram-posrtlve orgamsms should be consldered ln treatlng InfectiOnS caused by both Gram· negative and Gram-positive organlsms. . Based on rne m v1rro synergism between T1carclllln and genta· micln sulfate or tobramycm sulfate against certain stralns al Pseudomonas aeruqmosa. comblned therapy has been successlul. usina lulltherapeutlc dosages. . Culluring and susceptibihty testing should be perlormed lnlltally and during !rearment CONTRAINDICATIONS: A hlstory ol allergie reaction lo any al the peniclllins is a contraindicatron. WARNINGS: Anaph~laxis may occur. especially in patrents wilh an allergie dlathesis Check tor a history ol allergy .ra pemctlltns. cephalosporlns or orner allergens. Han allergie react1on occurs, the drug should be discontinued unless. rn the oprmon al !he physrclan. the condllion be mg treated ls llle·threatemng and amenable only lo Tlcarcillin therapy Serious anaphylactic reacuons requne Immediate emergency !rearment wllh eplnephnne, o•ygen. intravenous stermds

and~):a~a~:~tasg~c~~~mg high doses ol ncarclllin may develop hemorrhagic mamies talions associated wilh abnormahtres ol coagu· latlon tests. Pauents wrlh renal impaument. ln whom excret1on or Ticarcillln IS delayed, should be observed lor bleedong mamlesta· !IOns Such patients should be dosed surctly accordmg to recom· mandations Hbleeding mamlestauons appear. Trcar.crllm !rearment should be discontmued and. 11 necessary. appropnate therapy m· smuted PRECAUTIONS: During prolonged treatmenl, periodic checking lor organ system dyslunction (renal. hepallc and hematopmeiiC 1 rs alfvisable. Il overgrowth ol resrstanl 01gamsms occurs. the appro· priate therapy should be rnitrated . . . Slnce the theoretical sodium contentrs 52 mtlllequrvalents 1120 mg) per gram al Ticarcillin, electrolyte and card1ac status should be monitored carelully. .. . ln a rew patients receivmg intravenous T1carcllhn. hypokalemla has been reported Serum potassium should be measured periodically. USAGE DURING PREGNANCY: Reproduction studies h.ave been perlormed in m1ce and rats and have revealed no evidence o1 1mpa1red tenrllty or harm to !he fetus due to Ticarcilhn. rnere are no well-controlfed studres in pregnant women. but mvesugatronal e•perlence does not 1nclude any positive evidence ol adverse ellects on the fetus. Although lhere is no crearlr delined rrsk. such experience cannat exclude the possibility o rnlrequenl 01 sublle damage ta the fetus. Trcarcilhn should be used in pregnant women only when clearly needed. ADVERSE REACTIONS: The lollowmg adverse reactions .may occur. skln rashes. pruritus. urticaria .. drug lever. nausea, vom11mg, anem1a. thrombocytopenia. leukopema. neutropema, eosmoph.1ha. SGOT and SGPT elevauons have been reported. Pauents, especoally those with impaired renallunction. may experience convulsions or neuromuscular excitabihty when very h1gh doses or the drug are

adT~il ~~ctlons at the site al mrection have been reported. Vein irritallon and phlebllis can occur. part1cularly when undiluted solution is direclly lnjected lnlo the vem DOSAGE AND ADMINISTRATION: Usual adult recommended dos· age in bacterial septlcemia, respiratory tract infections. skln and soft-tissue tnlectlons intra·abdommal mlect1ons and 1nfecllons ol the lemale pelvis anil genital tract. is 3 grams by mtravenous rn· fusion every 3. 4 or 6 hours depending on weighl and severlly ol mlection· in uncompllcated urmary tract infections, 1 gram LM .. 01 direct r.ïJ Q.l d: in complleated urrnary tract inlectrons. 3 grams Q.l d. by 1V. Infusion. Please consul! oll1cial package insert lor details on dosages lor patients wllh renal insulliciency, ch1ldren. neonates and directrons lor use. Supplied 1 Gm. 3 Gm and 6 Gm Standard V1als 3 Gm and 6 Gm Piggyback Boilles 8

Beecham

labaratories

BAIST0L TEN .... F'55fE Jf6l0

The Problem Patient

Possible Pneumonie Plague R. RUSSELL MARTIN

BaylorCollegeq{Medlcine

Case Presentation A 21-year-old longshoreman was brought to the Ben Taub General Hospital by a flre department ambulance after the acute onset of septlc shock. He was responslve and communicative and provlded his own hlstory. On the afternoon of admission, whlle worklng at his usual job unloadlng a shlpment of fruit from Venezuela he experlenced chllls and malaise. He contlnued to work as best he could but became slcker as the day went on. When he went home (to a small bungalow near the Houston shlp channell. he had diffuse muscle aches, progressive dlfflculty ln breathlng. and felt lncreaslngly feverlsh. After he became prostrate. his roommate called the ambulance. and he was brought to the hospital around mldnlght. On physlcal examlnatlon, the patient was an acutely Ill. well-developed white male, wlth a temperature of 104.6 ° F. labo red respirations at 24/mlnute, regular pulse rate of llO/minute. and blood pressure of 60/0. Scat te red dl sere te petechiai lesions were noted on the skln of his trunk. extremltles. and face. These lesions varled ln size, were not ralsed, and were hemorrhaglc but dld not blanch on pressure. One of the palpebral conjunctlvae had a discrete petechial hemorrhage. The throat was dlffusely erythematous wlthout exudate. Scattered raies and rhonchl were present ln ali Jung fields. Moderate diffuse abdominal tenderness wlthout rebound was noted. The neurologie examlnatlon

Dr. Martin is Professor of Medidne, Micro· hlology and /mmunology, Bay/or Co/lege of Medicine, Houston.

24

revealed that the pattent was orlented and alert. However. over the next two hours he gradually became disortented. In routine laboratory studles the white count was elevated to 28.500, wlth a marked left shift of the differentiai count (lncludlng 4% metamyelocytes). Hemoglobln was 16.0 and hematocrlt 49%. Platelets were present but seemed on the smear to be ln reduced numbers. BUN, electrolytes, and llver functlon tests were ali Wlthln normalllmlts. A lumbar pu net ure was performed, yleldlng clear, colorless cerebral spinal fluld under normal pressure. The CSF contalned normal proteln and glucose and two PMN leukocytes/mm3. Chest x-rays showed a bilateral diffuse lnterstltlal lnflltrate. Abdominal films revealed moderate gas Wlthln the small and large bowels, wlth no locallzed abnormallttes or fluld levels. Because of the abnormal chest xray and physlcal examlnatlon of the chest, a nasotracheal asplrate was obtalned for gram staln and culture. The specimen showed a moderate number of PMNs, as weil as scattered pleomorphlc gram-negative rods wlth blpolar stalnlng. Aspiration of two of the skln lesions also revealed small numbers of pleomorphlc gram-negative rods, wlth rare PMNs. After four blood cultures were obtalned. therapy was inltlated wlth amplclllln. 2 gm every four hours: chloramphenlcol IV, 6 gm/day ln dlvlded doses: and gentamlcln IV, 100 mg every eight hours. Fluld therapy was monltored by central venous pressure measurements. Initial values were very low. Because of advanclng hypoxla (p02 35, pC02 28, pH 7.25) and a rapid deteriora-

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Uon ln mental status, the pattent was lntubated. and resplrator-asststed ventilation was lnltlated. Because the pattent worked at the Port of Houston docks unloadlng cargo from tropical countrles, the posslblllty of an unusual bactertal or paras! ttc Infection was consldered. The patlent's roommate, reached by telephone. revealed that the area around and under thelr bouse was lnfested wtth large rats. Because of this hlstmy and the demonstration of a pleomorphlc gram-negative bacterlum ln the resptratory secretions and ln the aspira te from the petechiai lesion, a gram staln was performed on materlal from one of the blood culture botties approxlmately 12 hours after lt had been obtalned. Pleomorphlc gram-negative rods slmllar to those seen prevtously ln the sputum and skln lesion were present ln the blood culture. At this Ume the dlagnosls of pneumonie plague was consldered. Telephone consultation was obtalned from laboratory personnel at the Center for Dtsease Control (CDCI ln Atlanta. who suggested that Glemsa staln mtght better demonstrate the morphology of the organlsm. This was done wlth slldes from the positive blood culture. The staln showed curved, blpolar-stalnlng organlsms, whlch lndeed resembled textbook plctures of Yersin la pestls. At this point considerable concern arose about the posslblllty of transmltttng a htghly lnfectlous agent to other patients ln the Intensive care unit where the pattent was belng treated. Adequate facllltles for resplratory Isolation were not avallable ln the ICU. But Institution of Isolation procedures would have requlred movtng the pattent from the ICU to a prlvate room, and tt was felt that the pattent was too Ul to tolerate such a move. Apprehension for the safety of the medical personnel and other patients conttnued untll the blood culture had been tested by fluorescent ml· croscopy at the CDC laboratory. 1t dtd not react wtth specifie fluorescent-tagged anttserum agatnst Y. pestls. This further testtng took an addtttonal 16 hours and would have taken longer were tt not for the co25

operation of helpful laboratory personnel, who ran the assay on a Sunday mornlng. Only then was the dlagnosls of pneumonie plague dlscarded. The blood culture (and the companton botties) later was shown to con tain a Bacteroldes specles and two other anaerobie organlsms. Whlle the definitive studles were belng performed on the culture Isotate, Important new cllnlcallnformation was obtalned. The patlent's roommate came to the hospital shortly after mldntght on the second hospital day, brlngtng a small lnk bottle fllled wlth a putrld llquld wlth a turbld sediment. He handed this to the physlclan on cali. lndlcatlng that this materlal represented marijuana mlxed wtth horse manure. The patient had mlxed these Ingredients wlth tap water, allowed 1t to ferment for three days, then asplrated and lnjected severa! mllllllters lntravenously. Gram staln of this materlal showed abundant gram-positive and

Hemo"bagic petecbiae lille tbese on foot U'ere scattered Ol'er trunll, face, and extremities of patient in sepl/c sbocll. lesions did not blancb on pressure.

gram-negative bacterla of varylng morphology. The pattent had a verystormy hospital course. requlrtng resplrator assistance for an acute resptratory dlstress syndrome. He recelved antlblotlc therapy and other supportlve measures for six weeks, then was

Remember

DLOPRIM~ the original (allopurinol) 100 and 300 mg Scored Tablets Thename

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Glemsa-stalned organlsms from blood culture resembled Yersinia pcstis, und pm•umonlc plague U'us suspected. cne ldentlfletl Bacteroldes and tu•u utber anaerobes.

dlscharged; he has been lost to follow-up.

The Case in Context This case lllustrates sorne of the problems that can occur when the posstblllty of a htghly transmissible Infection occurs ln an Intensive care situation. Unttl the question of pneumonie plague was settled. there was considerable concern about the safety of medical personnel and other patients who were ln proxlmlty to the lnfected pattent. Resptratory Isolation factlltles were Inadequate. and lt would have been necessary to compromise severely the supporttve care provlded for this desperately Ill pattent ln order ta achleve adequate Isolation agalnst alrborne dissemination of Infection. Ail the la bora tory

studtes seemed consistent wtth the tentative dtagnosls of pneumonie plague, untll the specifie fluorescent antlbody studtes were done. Another feature demonstrated by this case ls the bizarre and unusual Infections that can occur ln lntravenous drug abusers. There ls rarely the opportunlly to document as completely as we were able ln this case the source of polymlcrobtal bacteremta. Although staphylococcallnfectlon ls a predominant cause of septlc complications ln drug abusers, physlclans must be constantly alert to the posslblllty of other lnfecttng agents, particularly fungl and unusual gram-negative rods. The antlblotic therapy requlred may be qulte variable, and wlth deep fungl Infections. concomitant surglcal therapy may be lndlcated. The Isolation of more than one organlsm from a blood culture occurs when the bloodstream ls seeded from a focus, such as the gastrolntestlnal tract or a decubitus ulcer. where multiple organtsms have produced Infection. The other setttng ts self-Inoculation of polymlcroblal materlal, e.g., suspensions of feces. The management of the patient presented here was hampered by our Jack of knowledge of his hlstory of lntravenous drug abuse and by the red herrlngs ralsed by his occupattonal background and his home envlronment. Although most cases of Y. pestls Infection are the result of sylvattc plague, often transmttted by flea vectors prevlously harbored by lnfected prairie dogs or other small animais, the posslbtllty of lmported plague should continue to keep physlclans ln port cltles alert to the posslbillty of encounterlng an Infection. o

Selected Reading Pol and JO: Plague. In lnfecttous Diseases, 2nd ed, Hoeprich PD lEd). Harper & Row, Hagerstown. Md, 1977 Louria DB. Hensle T. Rose J: The major medical complications of heroin addiction. Ann Intern Med 67:1. 1967 Cherubin CE: The medical sequelae of narcotic addiction. Ann Intern Med 67:23. 1967 Reed WP, Palmer DL. Williams RC Jr, Klsch AL: Bubonlc plague ln the southwestern United States. Medicine 49:465, 1970 Butler T. Mahmoud AF. Warren KS: Algorlthms ln the diagnosis and management of exotlc dlseases: XXV. Plague. J Infect Dis 136:317, 1977

26

Hospital Practlce December 1979

KATO

(potassium chloride for oral solution) 20 mEq (1.5 g. KCI) Prescrlblng Information DESCRIPTION: Spra.y-dried toma.to powder containing 20 mEq potassium (eqUivalent to 1.5 g: KCI) per 6 grams powder (one dose) with natural and synthet1c fla.vors, spices and colors. Benzoic ac id and potassium benzoate added as preservatives. When reconstituted as directed. makes a pleasantly flavored. low sodium tomato juice drink. Each daily dose (2 packets) contains less than 10 mg. sodium. INDICATIONS: The prevention or correction of potassium deficit, particularly when accompanied by hypochloremic alkalosis in conjuncllon Wilh thiazide diuretic therapy, in digitalis intoxication. or as the result of long-lerm corticosteroid therapy, low dietary mtake of potassium, or excessive vomiting or diarrhea. CONTRAINDICATIONS: Potassium _is contraindicated in severe renal impairment mvolvmg oliguna, anuna or azotemla; in untreated Addison's disease. familial periodic paralysis, acute dehydration. heat cramps, hyperkalemia from any cause. Potassium chloride should not be employed in patients receiving potassiumsparing agents such as aldosterone antagonists and triamterene. PRECAUTIONS: KATO is a concentrate and should be laken only atter reconstituting with water as directed. This preparation. like other potassium supplements. 111ust be properfy diluted to avoid the possibility of gastrointestinal irritation. Do not use in patients with low urinary output or renal decompensation Administer with caution: it is impossible to assess accurately the daily dose required. Excessive dosage may result in potassium intoxication. Frequent checks of the clinical status of the patient. ECG and/or plasma potassium level should be made. High plasma concentrations of potassium ion may cause death through cardiac depression. arrhythmias or arrest. Use with caution in patients with cardiac disease. ADVERSE REACTIONS: Vomiting. diarrhea, nausea, and abdominal discomfort may occur. Gross overdosage may produce signs and symptoms of potassium Intoxication: mental contusion. llstlessness, paresthesia of the extremities. weakness and heaviness of legs. tlaccid paralysis. hyperkalemia, ECG abnormalities. tall in blood pressure, cardiac arrhythmias and heart block. The characteristic changes in the ECG are disappearance of the P wave. wldening and slurring of ORS complex, changes of the S-T segment. ta li peaked T waves. etc. TOXICITY: Potassium intoxication may result from overdosage of potassium or from therapeutic dosage in conditions stated under "Contraindications." Hyperkalemia, when detected, must be treated immediately because lethallevels can be reached in a tew hours. TREATMENT OF HYPERKALEMIA: 1. Dextrose solution 10% or 25% containing 10 units of crystalline insu lin per 20 g. dextrose. given 1. V. in a dose of 300cc to 500cc in an hour. 2. Adsorption and exchange of potassium usmg sod1um or ammonium cycle cation exchange resin, orally or as retention enema. 3. Hemodialysis or peritoneal dialysis. 4. Elimination of potassium-containing toods and medicaments. Warning: Digitalis toxicity can be precipitated by lowering the plasma potassium concentration too rapidly in digitalized patients. ADMINISTRATION AND DOSAGE: Mi x with water to make a pleasant tomato juice drink. Each 6 gram unit dose packet provides 20 mEq of potassium. Usual adult dose-1 packet of KATO mixed wlth about 2 ounces of water twice daily-supplies 40 mEq potassium per day. Take with meals or follow with 1'2 glass of water. Larger doses may be required. but should be administered under close supervision because of the possibility of potassium intoxication. HOW SUPPUED: Cartons of 30 and 120 6 gram unit dose packets, 20 mEq each. 02-488-30

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