Yersinia pestis infection laboratory findings: Difference between revisions
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==Overview== | ==Overview== | ||
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. Bubonic plague is diagnosed by [[gram stain]] and | 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. 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 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> 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, 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> | 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> | ||
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=====Blood Work-Up===== | =====Blood Work-Up===== | ||
*Leukoyctosis and neutrophilia with left shift | *[[Leukoyctosis]] and [[neutrophilia]] with left shift | ||
*Thrombocytopenia | *[[Thrombocytopenia]] | ||
*Elevated D-dimer | *Elevated [[D-dimer]] | ||
*Elevated transaminase and bilirubin | *Elevated [[transaminase]] and [[bilirubin]] concentrations | ||
*Elevated creatinine | *Elevated [[creatinine]] | ||
*Hypoglycemia | *[[Hypoglycemia]] | ||
*Elevated ''Y. pestis'' F1 antigen | *Elevated ''Y. pestis'' F1 antigen | ||
====Urine Work-Up==== | ====Urine Work-Up==== | ||
*Proteinuria | *[[Proteinuria]] | ||
=====Peripheral Smear===== | =====Peripheral Smear===== | ||
| Line 40: | Line 40: | ||
=====Gram Stain===== | =====Gram Stain===== | ||
*Small gram-negative coccobacilli | *Small [[gram-negative]] coccobacilli | ||
=====Culture of Fluids===== | =====Culture of Fluids===== | ||
* | *Positive for ''Y. pestis'' | ||
=====Cerebrospinal Fluid Analysis===== | =====Cerebrospinal Fluid Analysis===== | ||
*Pleocytosis with polymorphonuclear leukocyte predominance | *[[Pleocytosis]] with polymorphonuclear leukocyte predominance | ||
*Limulus test confirms endotoxin | *Limulus test confirms [[endotoxin]] | ||
==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.<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> | 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 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> | [[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> | ||
==References== | ==References== | ||
Revision as of 01:23, 26 July 2014
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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
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. 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
- 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
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
Cerebrospinal Fluid Analysis
- Pleocytosis with polymorphonuclear leukocyte predominance
- Limulus test confirms endotoxin
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]
References
- ↑ 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.
- ↑ 2.0 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) - ↑ 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) - ↑ 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.
- ↑ "International meeting on preventing and controlling plague: the old calamity still has a future". Wkly Epidemiol Rec. 81 (28): 278–84. 2006. PMID 16841399.