Yersinia pestis infection history and symptoms

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Symptoms of plague may be differentiated by type: Bubonic, septicemic, and pneumonic. Although all 3 types share constitutional symptoms, key features differentiate them from one another. Not only do the 3 types differ in symptoms, but also in treatment and prognosis. Bubonic plague is characterized by the presence of painful and tender lymphadenopathy, called buboes. Less pathognomonic features are found in other types of plague, making their diagnosis more difficult. Septicemic plague follows the course, along with signs and symptoms, of a gram-negative bacilli and pneumonic plague presents with a virulent pneumonia.

History and Symptoms

The plague may have any of 3 classic presentations:

• Bubonic plague
• Septicemic plague
• Pneumonic plague

While bubonic plaque is the most common type of plague in humans, septicemic is the most fatal and often leads to death in all untreated cases. One patient may have more than one plague type, especially late in the course of the disease. All plague types include constitutional non-specific symptoms, such as fever, malaise, and weight loss. However, it is important to differentiate the types of plague based on patient symptoms for therapeutic and prognostic purposes.

Other less common plague infections include:

• Pharyngeal plague
• Gastrointestinal plague

The following table compares the various types of plague and their key clinical features.

Various Types of Plague and Clinical Features

Subtype	Mode of Transmission	Manifestations	Complications
Bubonic Plague	Fleabite or exposure to animals infected by fleabite, such as squirrels, rabbits, dogs, and cats. Direct exposure of infected skin or mucus membranes	Symptoms generally start 2-6 days after exposure: Papules, vesicles, pustules, ulcers, or eschar at inoculation site surrounded by erythematous, edematous and adherent skin Abrupt onset of headache, chills, fever, and malaise 1-10 cm painful and tender lymph nodes, called buboes, that appear after 24 hours. Lymphadenopathy may involve any site (superficial lymph nodes such as inguinal, axillary, popliteal, supraclavicular, cervical, epitrochlear, or even deeper lymph nodes such as intra-abdominal or intra-thoracic). Buboes may become fluctuant and suppurative.	Symptoms of complications may also arise. The most common complications are: Septicemia Pneumonia Meningitis
Septicemic Plague	Primary: Y. pestis bacteremia after cutaneous exposure Secondary: Local infection by bubonic or pneumonic plague followed by infection spread	Usually affects patients older than 60 years of age. Characteristically, there is absence of lymphadenopathy, which differentiates it from bubonic plague. Signs and symptoms of gram-negative sepsis may predominate: Fever Tachypnea Tachycardia Altered mental status Hypotension	Black death: Gangrene of distal upper and lower extremities and tip of the nose due to small vessel thrombosis Disseminated intravascular coagulopathy (DIC) Adult respiratory distress syndrome (ARDS) Meningitis Pneumonia Hepatic or splenic abscess Endophthalmitis Generalized lymphadenopathy
Pneumonic Plague	Primary: Ingestion or inhalation of Y. pestis Secondary: Infection with another plague type that eventually involves the lungs	Respiratory symptoms at 3-5 days after exposure causing a virulent pneumonia are the hallmark of pneumonic plague: Chest pain with splinting Dyspnea Cough Hemoptysis that starts as blood-tinged sputum, but rapidly develops into bloody mucupurulent sputum	Septicemia

^{Adapted from Koirala et al. Plague: disease, management, and recognition of act of terrorism. Infect Dis Clin N Am.2006;20:273-87}

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