CDC Case Challenge: Four People With Cough and Dyspnea After Attending a Baseball Game

Christina A. Nelson, MD, MPH; Katharine M. Cooley, MPH; David W. McCormick, MD, MPH


October 07, 2021

Editorial Collaboration

Medscape &

Prompt treatment with antibiotics is essential. If plague is suspected, healthcare providers should begin antibiotic treatment without waiting for confirmation of diagnosis. Guidelines recently published by the Centers for Disease Control and Prevention (CDC) describe treatment and prophylaxis options for patients with plague or potentially exposed to Y pestis.[10] Recommendations include special populations, such as pregnant women, neonates, and geriatric and immunocompromised persons.

First-line antimicrobials recommended for treatment of adults with primary pneumonic plague include fluoroquinolones (ciprofloxacin, levofloxacin, moxifloxacin) and aminoglycosides (streptomycin, gentamicin).[10] Naturally occurring antimicrobial resistance in Y pestis is extremely rare; however, there is potential for engineered resistance.[10,11,12] In the aftermath of a bioterrorist attack, clinicians should treat patients initially with two distinct antimicrobial classes to increase the likelihood that they will receive at least one effective agent.[10] Trimethoprim-sulfamethoxazole is an alternative option for treatment and prophylaxis of plague but is not first-line.

Recommended first-line antimicrobial treatment for pregnant women with pneumonic, septicemic, bubonic, or pharyngeal plague is gentamicin plus either ciprofloxacin or levofloxacin.[10] Dual therapy with two distinct classes of antimicrobials is indicated for pregnant women with plague due to the high maternal morbidity and mortality from plague, the risk for perinatal transmission, and the lack of pharmacokinetics data for various antimicrobials among pregnant women.

Treatment recommendations for geriatric or immunocompromised adult patients do not differ from recommendations for other adults; however, clinicians should be aware of the potential for presence of polypharmacy.[10]

Children may be at higher risk for infection and severe disease following the intentional release of a bioterrorism agent due to their closer proximity to the ground, increased respiratory rate, larger relative body surface area, and other factors.[13,14] In this scenario, patient 4 had sepsis upon presentation to the ED. Pediatric patients (> 1 month to ≤ 17 years of age) with primary pneumonic and septicemic plague can receive first-line treatment with ciprofloxacin, levofloxacin, gentamicin, or streptomycin.[10]

Following a known intentional release of Y pestis, antimicrobial prophylaxis should be considered for anyone who was potentially exposed.[10] In this scenario, this could include attendees of the baseball game who were exposed, as well as any persons who had close (< 6 ft), sustained contact with symptomatic patients (eg, patient 2's son, patient 4's mother, healthcare providers). First-line prophylaxis options include ciprofloxacin, levofloxacin, moxifloxacin, and doxycycline. Prophylaxis should be continued for 7 days.[10]

Clinicians should report a suspected case of bioterrorism-related plague to the local or state health department and CDC as soon as possible.

Y pestis can be transmitted from person to person via large respiratory droplets that do not remain suspended in the air for prolonged periods. Transmission from person to person requires exposure within 6 feet.[10] Healthcare providers should use respiratory droplet precautions when caring for patients with pneumonic plague.

Y pestis has a characteristic bipolar staining pattern, or safety pin appearance, on Giemsa, Wright, or Wayson stain.[15] A presumptive diagnosis of plague can be made by PCR or detection of Y pestis–specific antigens in a clinical specimen by direct fluorescent antibody assay or immunohistochemical assay (16). A single elevated serum antibody titer to Y pestis fraction 1 (F1) antigen also provides presumptive evidence of plague.[16] Plague can be confirmed by culture of Y pestis from a clinical specimen, with culture identification validated by a secondary assay (eg, bacteriophage lysis assay, direct fluorescent antibody assay).[16] These tests are normally conducted by CDC or a Laboratory Response Network laboratory. Plague can also be confirmed by a fourfold or greater change in paired serum antibody titers to Y pestis F1 antigen; however, this approach is not useful in the acute setting since it requires collection of a convalescent serum specimen.