On August 5, 1983, plague was diagnosed in a 13-year-old girl
in
South Carolina. She became ill while en route to Maryland from her
previous residence in Santa Fe, New Mexico, and subsequently died.
The area in which she had lived had been recognized as a locality
where sylvatic plague was enzootic.
On July 25, the girl, a horsewoman who spent considerable time
outdoors, handled and then released a wild chipmunk. On July 27,
she
flew to Atlanta, Georgia, and spent the night with friends; the
following day she was driven to Seneca, South Carolina. That
evening,
she complained of a sore throat and tenderness in her right groin
and
reportedly had a temperature of 40.0 C (104 F). On July 29, she
saw a
physician, who noted an oral temperature of 38.3 C (101 F),
pharyngeal
erythema, tender cervical lymph nodes, and a 1-x-2-centimeter
tender
right inguinal lymph node. Laboratory tests, including complete
blood
count, urinalysis, and throat culture, and tests for mononucleosis,
were done, and oral penicillin was prescribed. Three days later
she
was seen again, still febrile and with expanding right inguinal
nodes. Her white blood cell count was 20,500, and a chest x-ray
was
normal. Because of her history of residence in a plague-enzootic
state, a diagnosis of plague was considered. She was hospitalized
and
given parenteral therapy, including streptomycin. By the following
morning, she was tachypneic, with productive bloody sputum, and
appeared moribund. She was transferred to a large, regional
medical
center where, despite intensive supportive care and therapy with
intravenous chloramphenicol, she developed overwhelming sepsis and
died on August 2. A chest radiograph taken before death revealed
extensive pulmonary infiltrates.
Ante-mortem aspiration of the right inguinal lymph node
demonstrated gram-negative bipolar staining bacilli on Giemsa
stain.
Both this aspirate and multiple cultures of blood yielded Yersinia
pestis. In addition, fluorescent antibody (FA) stains for Y.
pestis
were positive for specimens consisting of blood smears, culture
material, and pulmonary secretions.
Reported by D Irvine, MD, Clemson, E Bryant, MD, F Cantrell, MD,
Greenville, South Carolina, Hospital System, J Pruitt, MD, Oconee
Memorial Hospital, Seneca, H Dowda, PhD, AF DiSalvo, MD, RL Parker,
DVM, State Epidemiologist, South Carolina Dept of Health and
Environment Control; RK Sikes, DVM, State Epidemiologist, Georgia
Dept
of Human Resources; JM Mann, MD, State Epidemiologist, New Mexico
State Health and Environment Dept; Div of Field Svcs, Epidemiology
Program Office, Div of Vector-Borne Diseases, Center for Infectious
Diseases, CDC.
Editorial Note
Editorial Note: This is the fifth documented case of plague east
of
the hundredth meridian (south central Texas to north central North
Dakota), excluding laboratory accidents, since 1920. All five
patients were exposed in enzootic areas (four in the western United
States, one in Vietnam). Considering this patient's outdoor
activities and area of residence, exposure possibilities are
numerous;
her exact exposure will probably never be known, since the chipmunk
was not captured. That she was able to handle the animal suggests
it
was not healthy.
Because the patient had no evidence of pneumonia before
hospitalization, no chemoprophylaxis was recommended for the
friends
with whom she stayed in Georgia; there were no secondary cases.
Based
on the clinical picture and the positive FA results from sputum, it
appears that pneumonic plague and the potential for human-to-human
transmission existed terminally. Local health-care providers had
placed her in complete isolation before this development. Hospital
staff directly in contact with her at this point were placed on
prophylactic tetracycline and followed up for evidence of illness.
No
secondary cases appeared during the expected incubation period.
Primary pneumonic plague in the United States has been
described
as rare, with only three cases between 1926 and 1977--all in
laboratory workers (1). However, since 1975, four persons have
developed primary pneumonic plague, presumably from exposure to
household pets with secondary plague pneumonia (2,3). Recent
investigations suggest that plague pneumonia (i.e., secondary to
bubonic plague) is more common (4). Thus far in 1983, 24 cases of
human plague have originated in New Mexico, and three (13%) of them
have had pneumonic involvement (5). No transmission to contacts of
patients with pneumonic plague has been documented in the United
States since 1925.
Delay in diagnosing and treating plague increases the potential
for pulmonary involvement and person-to-person transmission. In
the
past 8 years, 32 (20%) of 164 plague patients reported to CDC have
developed pulmonary disease. Three (33%) of the nine plague
patients
who had been interstate travelers developed pneumonia, including
the
girl reported here (Table 1) (3). In addition to plague cases
among
persons traveling between states (3,6), one case was documented in
a
serviceman returning to Texas from Vietnam in 1966 (7). This case
emphasizes the need for physicians in all parts of the country to
consider plague in the differential diagnosis of patients with
fever
and/or lymphadenopathy who have histories of recent travel or
residence in areas where plague is enzootic/endemic.
References
Mandell GL, Douglas RG, Jr, Bennett JE. Principles and
practice
of infectious diseases. J Wiley & Sons, NY. 1979:1794.
White ME, Gordon D, Poland JD, Barnes AM. Recommendations for
the
control of Yersinia pestis infections. Recommendations from
the
CDC. Infect Control 1980; 1:324-9.
Mann JM. New Mexico State Health & Environment Dept.
Unpublished
data.
Caten J, Kartman L. Human plague in the United States during
1966: case reports. Southwestern Med 1968; 49:102-8.
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