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Plague -- South Carolina

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

  1. Mandell GL, Douglas RG, Jr, Bennett JE. Principles and practice of infectious diseases. J Wiley & Sons, NY. 1979:1794.

  2. Poland JD. Plague. In: Hoeprich PD, ed. Infectious diseases, 3rd ed. Philadelphia: Harper and Row 1983: 1227-37.

  3. CDC. Unpublished data.

  4. 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.

  5. Mann JM. New Mexico State Health & Environment Dept. Unpublished data.

  6. Mann JM, Schmid GP, Stoesz PA, Skinner MD, Kaufmann AF. Peripatetic plague. JAMA 1982;247:47-8.

  7. Caten J, Kartman L. Human plague in the United States during 1966: case reports. Southwestern Med 1968; 49:102-8.



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