Plague (pestis) is an acute zoonotic natural focal infectious disease with a predominantly transmissible pathogen transmission mechanism, which is characterized by intoxication, damage to the lymph nodes, skin and lungs. It is classified as a particularly dangerous, conventional disease.

Codes according to ICD -10

A20.0. Bubonic plague.
A20.1. Cellulocutaneous plague.
A20.2. Pneumonic plague.
A20.3. Plague meningitis.
A20.7. Septicemic plague.
A20.8. Other forms of plague (abortive, asymptomatic, minor).
A20.9. Unspecified plague.

Etiology (causes) of plague

The causative agent is a gram-negative small polymorphic non-motile bacillus Yersinia pestis of the Enterobacteriaceae family of the genus Yersinia. It has a mucous capsule and does not form spores. Facultative anaerobe. Dyed with bipolar aniline dyes (more intense at the edges). There are rat, marmot, gopher, field and sand lance varieties of the plague bacterium. Grows on simple nutrient media with the addition of hemolyzed blood or sodium sulfate, the optimal temperature for growth is 28 ° C. It occurs in the form of virulent (R-forms) and avirulent (S-forms) strains. Yersinia pestis has more than 20 antigens, including a thermolabile capsular antigen, which protects the pathogen from phagocytosis by polymorphonuclear leukocytes, a thermostable somatic antigen, which includes V- and W-antigens, which protect the microbe from lysis in the cytoplasm of mononuclear cells, ensuring intracellular reproduction, LPS etc. The pathogenicity factors of the pathogen are exo- and endotoxin, as well as aggression enzymes: coagulase, fibrinolysin and pesticins. The microbe is stable in the environment: it persists in soil for up to 7 months; in corpses buried in the ground, up to a year; in bubo pus - up to 20–40 days; on household items, in water - up to 30–90 days; tolerates freezing well. When heated (at 60 °C it dies in 30 s, at 100 °C - instantly), drying, exposure to direct sunlight and disinfectants (alcohol, chloramine, etc.), the pathogen is quickly destroyed. It is classified as pathogenicity group 1.

Epidemiology of the plague

The leading role in preserving the pathogen in nature is played by rodents, the main ones being marmots (tarbagans), ground squirrels, voles, gerbils, as well as lagomorphs (hares, pikas). The main reservoir and source in anthropurgic foci are gray and black rats, less often - house mice, camels, dogs and cats. A person suffering from pneumonic plague is especially dangerous. Among animals, the main distributor (carrier) of plague is the flea, which can transmit the pathogen 3–5 days after infection and remains infective for up to a year. Transmission mechanisms are varied:

• transmissible - when bitten by an infected flea;
• contact - through damaged skin and mucous membranes when skinning sick animals; slaughter and cutting of camel, hare carcasses, as well as rats, tarbagans, which are used as food in some countries; in contact with the secretions of a sick person or objects contaminated by him;
• fecal-oral - when eating insufficiently heat-treated meat from infected animals;
• aspiration - from a person suffering from pulmonary forms of plague.

Diseases in humans are preceded by epizootics among rodents. The seasonality of the disease depends on the climate zone and in countries with temperate climate registered from May to September. Human susceptibility is absolute in all age groups and for any mechanism of infection. A patient with the bubonic form of plague before the opening of the bubo does not pose a danger to others, but when it passes into the septic or pneumonic form, he becomes highly infectious, releasing the pathogen with sputum, bubo secretions, urine, and feces. Immunity is unstable, repeated cases of the disease have been described.

Natural foci of infection exist on all continents, with the exception of Australia: in Asia, Afghanistan, Mongolia, China, Africa, South America, where about 2 thousand cases of illness are registered annually. In Russia, there are about 12 natural focal zones: in the North Caucasus, Kabardino-Balkaria, Dagestan, Transbaikalia, Tuva, Altai, Kalmykia, Siberia and the Astrakhan region. Anti-plague specialists and epidemiologists are monitoring the epidemic situation in these regions. Over the past 30 years, cluster outbreaks have not been registered in the country, and the incidence rate has remained low - 12–15 episodes per year. Each case of human illness must be reported to the territorial center of Rospotrebnadzor in the form of an emergency notification, followed by the announcement of quarantine. International rules specify quarantine lasting 6 days, observation of persons in contact with the plague is 9 days.

Currently, the plague is included in the list of diseases, the causative agent of which can be used as a means of bacteriological weapons (bioterrorism). Laboratories have obtained highly virulent strains that are resistant to common antibiotics. In Russia there is a network of scientific and practical institutions to combat infection: anti-plague institutes in Saratov, Rostov, Stavropol, Irkutsk and anti-plague stations in the regions.

Plague prevention measures

Nonspecific

• Epidemiological surveillance of natural plague foci.
• Reducing the number of rodents, carrying out deratization and disinfestation.
• Constant monitoring of the population at risk of infection.
• Preparing medical institutions and medical personnel to work with plague patients, conducting awareness-raising work among the population.
• Prevention of pathogen importation from other countries. The measures to be taken are set out in the International Health Regulations and the Sanitation Regulations.

Specific

Specific prevention consists of annual immunization with a live anti-plague vaccine of persons living in epizootic outbreaks or traveling there. People who come into contact with plague patients, their belongings, and animal corpses are given emergency chemoprophylaxis (Table 17-22).

Table 17-22. Application schemes antibacterial drugs for emergency prevention of plague

A drug	Mode of application	Single dose, g	Frequency of application per day	Course duration, days
Ciprofloxacin	Inside	0,5	2	5
Ofloxacin	Inside	0,2	2	5
Pefloxacin	Inside	0,4	2	5
Doxycycline	Inside	0,2	1	7
Rifampicin	Inside	0,3	2	7
Rifampicin + ampicillin	Inside	0,3 + 1,0	1 + 2	7
Rifampicin + ciprofloxacin	Inside	0,3 + 0,25	1	5
Rifampicin + ofloxacin	Inside	0,3 + 0,2	1	5
Rifampicin + pefloxacin	Inside	0,3 + 0,4	1	5
Gentamicin	V/m	0,08	3	5
Amikacin	V/m	0,5	2	5
Streptomycin	V/m	0,5	2	5
Ceftriaxone	V/m	1	1	5
Cefotaxime	V/m	1	2	7
Ceftazidime	V/m	1	2	7

Pathogenesis of plague

The causative agent of plague enters the human body most often through the skin, less often through the mucous membranes of the respiratory tract and digestive tract. Changes in the skin at the site of pathogen penetration (primary focus - phlyctena) rarely develop. Lymphogenously from the site of introduction, the bacterium enters the regional lymph node, where it multiplies, which is accompanied by the development of serous-hemorrhagic inflammation, spreading to surrounding tissues, necrosis and suppuration with the formation of a plague bubo. When the lymphatic barrier breaks through, hematogenous dissemination of the pathogen occurs. Entry of the pathogen via the aerogenic route promotes the development of an inflammatory process in the lungs with melting of the walls of the alveoli and concomitant mediastinal lymphadenitis. Intoxication syndrome is characteristic of all forms of the disease, is caused by the complex action of pathogen toxins and is characterized by neurotoxicosis, ITS and thrombohemorrhagic syndrome.

Clinical picture (symptoms) of plague

The incubation period lasts from several hours to 9 days or more (on average 2–4 days), shortening in the primary pulmonary form and lengthening in vaccinated individuals.
or receiving prophylactic medications.

Classification

There are localized (cutaneous, bubonic, cutaneous bubonic) and generalized forms of plague: primary septicemic, primary pulmonary, secondary septic, secondary pulmonary and intestinal.

Main symptoms and dynamics of their development

Regardless of the form of the disease, plague usually begins suddenly, and the clinical picture from the first days of the disease is characterized by a pronounced intoxication syndrome: chills, high fever (≥39 ° C), severe weakness, headache, body aches, thirst, nausea, and sometimes vomiting. The skin is hot, dry, the face is red and puffy, the sclera is injected, the conjunctiva and mucous membranes of the oropharynx are hyperemic, often with pinpoint hemorrhages, the tongue is dry, thickened, covered with a thick white coating (“chalky”). Later, in severe cases, the face becomes haggard, with a cyanotic tint, and dark circles under the eyes. Facial features become sharper, an expression of suffering and horror appears (“plague mask”). As the disease progresses, consciousness is impaired, hallucinations, delusions, and agitation may develop. Speech becomes slurred; coordination of movements is impaired. Appearance and the behavior of patients resembles a state of alcohol intoxication. Characterized by arterial hypotension, tachycardia, shortness of breath, cyanosis. In severe cases of the disease, bleeding and vomiting mixed with blood are possible. The liver and spleen are enlarged. Oliguria is noted. The temperature remains constantly high for 3–10 days. In the peripheral blood - neutrophilic leukocytosis with a shift to the left. In addition to the described general manifestations of plague, lesions characteristic of individual clinical forms of the disease develop.

Cutaneous form is rare (3–5%). At the site of the entrance gate of infection, a spot appears, then a papule, a vesicle (phlyctena), filled with serous-hemorrhagic contents, surrounded by an infiltrated zone with hyperemia and edema. Phlyctena is characterized by severe pain. When it is opened, an ulcer forms with a dark scab at the bottom. A plague ulcer has a long course and heals slowly, forming a scar. If this form is complicated by septicemia, secondary pustules and ulcers occur. The development of a regional bubo (cutaneous bubonic form) is possible.

Bubonic form occurs most often (about 80%) and is distinguished by its relatively benign course. From the first days of the disease, sharp pain appears in the area of ​​the regional lymph nodes, which makes movement difficult and forces the patient to take a forced position. The primary bubo, as a rule, is single; multiple buboes are less often observed. In most cases, the inguinal and femoral lymph nodes are affected, and somewhat less frequently, the axillary and cervical lymph nodes. The size of the bubo varies from a walnut to a medium-sized apple. Vivid features are sharp pain, dense consistency, adhesion to the underlying tissues, smoothness of contours due to the development of periadenitis. The bubo begins to form on the second day of illness. As it develops, the skin over it turns red, shiny, and often has a cyanotic tint. At the beginning it is dense, then it softens, fluctuation appears, and the contours become unclear. On the 10th–12th day of illness it opens - a fistula and ulceration form. With a benign course of the disease and modern antibiotic therapy, its resorption or sclerosis is observed. As a result of hematogenous introduction of the pathogen, secondary buboes can form, which appear later and are small in size, less painful and, as a rule, do not suppurate. A serious complication of this form can be the development of a secondary pulmonary or secondary septic form, which sharply worsens the patient’s condition, even leading to death.

Primary pulmonary form It occurs rarely, during periods of epidemics in 5–10% of cases and represents the most dangerous epidemiologically and severe clinical form of the disease. It begins sharply, violently. Against the background of a pronounced intoxication syndrome, a dry cough, severe shortness of breath, and cutting pain in the chest appear from the first days. The cough then becomes productive, with the production of sputum, the amount of which can vary from a few spits to huge quantities, it is rarely absent at all. The sputum, at first foamy, glassy, ​​transparent, then takes on a bloody appearance, later becomes purely bloody, and contains a huge amount of plague bacteria. It usually has a liquid consistency - one of the diagnostic signs. Physical data are scanty: a slight shortening of the percussion sound over the affected lobe; on auscultation, there are not a lot of fine wheezes, which clearly does not correspond to the general serious condition of the patient. The terminal period is characterized by an increase in shortness of breath, cyanosis, development of stupor, pulmonary edema and ITS. Blood pressure drops, the pulse quickens and becomes thread-like, heart sounds are muffled, hyperthermia is replaced by hypothermia. Without treatment, the disease ends in death within 2–6 days. With early use of antibiotics, the course of the disease is benign and differs little from pneumonia of other etiologies, as a result of which late recognition of the pneumonic form of plague and cases of the disease in the patient’s environment are possible.

Primary septic form It happens rarely - when a massive dose of the pathogen enters the body, usually by airborne droplets. It begins suddenly, with pronounced symptoms of intoxication and the subsequent rapid development of clinical symptoms: multiple hemorrhages on the skin and mucous membranes, bleeding from internal organs(“black plague”, “black death”), mental disorders. Signs of cardiovascular failure progress. The patient's death occurs within a few hours from ITS. There are no changes at the site of introduction of the pathogen and in the regional lymph nodes.

Secondary septic form complicates other clinical forms of infection, usually bubonic. Generalization of the process significantly worsens the general condition of the patient and increases his epidemiological danger to others. The symptoms are similar to the clinical picture described above, but differ in the presence of secondary buboes and a longer duration. With this form of the disease, secondary plague meningitis often develops.

Secondary pulmonary form as a complication occurs in localized forms of plague in 5–10% of cases and sharply worsens the overall picture of the disease. Objectively, this is expressed by an increase in symptoms of intoxication, the appearance of chest pain, coughing, followed by the release of bloody sputum. Physical data make it possible to diagnose lobular, less often pseudolobar pneumonia. The course of the disease during treatment can be benign, with a slow recovery. The addition of pneumonia to low-infectious forms of plague makes patients the most dangerous in epidemiological terms, so each such patient must be identified and isolated.

Some authors distinguish the intestinal form separately, but most clinicians tend to consider intestinal symptoms (severe abdominal pain, profuse mucous-bloody stool, bloody vomiting) as manifestations of the primary or secondary septic form.

With repeated cases of the disease, as well as with plague in people who have been vaccinated or received chemoprophylaxis, all symptoms begin and develop gradually and are more easily tolerated. In practice, such conditions are called “minor” or “outpatient” plague.

Complications of the plague

There are specific complications: ITS, cardiopulmonary failure, meningitis, thrombohemorrhagic syndrome, which lead to the death of patients, and nonspecific complications caused by endogenous flora (phlegmon, erysipelas, pharyngitis, etc.), which are often observed against the background of improvement of the condition.

Mortality and causes of death

In the primary pulmonary and primary septic form without treatment, mortality reaches 100%, most often by the 5th day of illness. In the bubonic form of plague, the mortality rate without treatment is 20–40%, which is due to the development of a secondary pulmonary or secondary septic form of the disease.

Diagnosis of plague

Clinical diagnosis

Clinical and epidemiological data allow one to suspect the plague: severe intoxication, the presence of an ulcer, bubo, severe pneumonia, hemorrhagic septicemia in persons located in the natural focal zone for the plague, living in places where epizootics (deaths) among rodents were observed or there is an indication of registered cases of illness. Every suspicious patient should be examined.

Specific and nonspecific laboratory diagnostics

The blood picture is characterized by significant leukocytosis, neutrophilia with a shift to the left and an increase in ESR. Protein is found in the urine. During an X-ray examination of the chest organs, in addition to enlarged mediastinal lymph nodes, one can see focal, lobular, less often pseudolobar pneumonia, and in severe cases - RDS. In the presence of meningeal signs (stiff neck muscles, positive Kernig's sign), a spinal puncture is necessary. In the CSF, three-digit neutrophilic pleocytosis, a moderate increase in protein content and a decrease in glucose levels are more often detected. For specific diagnostics, bubo punctate, ulcer discharge, carbuncle, sputum, nasopharyngeal smear, blood, urine, feces, CSF, and sectional material are examined. The rules for collecting material and its transportation are strictly regulated by the International Health Regulations. The material is collected using special dishes, containers, and disinfectants. The staff works in anti-plague suits. A preliminary conclusion is given on the basis of microscopy of smears stained with Gram, methylene blue, or treated with a specific luminescent serum. Detection of ovoid bipolar rods with intense staining at the poles (bipolar staining) suggests a diagnosis of plague within an hour. For final confirmation of the diagnosis, isolation and identification of the culture, the material is sown on agar in a Petri dish or in broth. After 12–14 hours, characteristic growth appears in the form broken glass(“laces”) on agar or “stalactites” in broth. The final identification of the culture is made on the 3rd–5th day.

The diagnosis can be confirmed by serological studies of paired sera in the RPGA, but this method has a secondary diagnostic value. Pathological changes in intraperitoneally infected mice and guinea pigs are studied after 3–7 days, with the inoculation of biological material. Similar methods of laboratory isolation and identification of the pathogen are used to identify plague epizootics in nature. For research, materials are taken from rodents and their corpses, as well as fleas.

Differential diagnosis

The list of nosologies with which differential diagnosis must be carried out depends on the clinical form of the disease. The cutaneous form of plague is differentiated from the cutaneous form anthrax, bubonic - from the cutaneous form of tularemia, acute purulent lymphadenitis, sodoku, benign lymphoreticulosis, venereal granuloma; pulmonary form - from lobar pneumonia, pulmonary form of anthrax. The septic form of plague must be distinguished from meningococcemia and other hemorrhagic septicemia. Diagnosis of the first cases of the disease is especially difficult. Epidemiological data are of great importance: stay in foci of infection, contact with rodents with pneumonia. It should be borne in mind that early use of antibiotics modifies the course of the disease. Even the pneumonic form of plague in these cases can be benign, but the patients still remain infectious. Considering these features, in the presence of epidemic data, in all cases of diseases occurring with high fever, intoxication, lesions of the skin, lymph nodes and lungs, plague should be excluded. In such situations, it is necessary to conduct laboratory tests and involve anti-plague service specialists. The criteria for differential diagnosis are presented in the table (Tables 17-23).

Table 17-23. Differential diagnosis of plague

Nosological form	General symptoms	Differential criteria
Anthrax, cutaneous form	Fever, intoxication, carbuncle, lymphadenitis	Unlike the plague, fever and intoxication appear on the 2nd–3rd day of illness, the carbuncle and the surrounding area of ​​edema are painless, there is eccentric growth of the ulcer
Tularemia, bubonic form	Fever, intoxication, bubo, hepatolienal syndrome	Unlike the plague, fever and intoxication are moderate, the bubo is slightly painful, mobile, with clear contours; suppuration is possible in the 3rd–4th week and later, after the temperature has normalized and the patient’s condition is satisfactory, there may be secondary buboes
Purulent lymphadenitis	Polyadenitis with local soreness, fever, intoxication and suppuration	Unlike the plague, there is always a local purulent focus (felon, suppurating abrasion, wound, thrombophlebitis). The appearance of local symptoms is preceded by fever, usually moderate. Intoxication is mild. There is no periadenitis. The skin over the lymph node is bright red, its enlargement is moderate. There is no hepatolienal syndrome
Lobar pneumonia	Acute onset, fever, intoxication, possible sputum mixed with blood. Physical signs of pneumonia	Unlike the plague, intoxication increases by the 3rd–5th day of illness. The symptoms of encephalopathy are not typical. Physical signs of pneumonia are clearly expressed, sputum is scanty, “rusty”, viscous

Indications for consultation with other specialists

Consultations are usually carried out to clarify the diagnosis. If the bubonic form is suspected, a consultation with a surgeon is indicated; if the pulmonary form is suspected, a consultation with a pulmonologist is indicated.

An example of a diagnosis formulation

A20.0. Plague, bubonic form. Complication: meningitis. Heavy current.
All patients with suspected plague are subject to emergency hospitalization on special transport to an infectious diseases hospital, in a separate box, in compliance with all anti-epidemic measures. Personnel caring for plague patients must wear a protective anti-plague suit. Household items in the ward and the patient's excretions are subject to disinfection.

Treatment of plague

Mode. Diet

Bed rest during the febrile period. There is no special diet provided. It is advisable to have a gentle diet (table A).

Drug therapy

Etiotropic therapy should be started if plague is suspected, without waiting for bacteriological confirmation of the diagnosis. It includes the use of antibacterial drugs. When studying natural strains of plague bacteria in Russia, no resistance to common antimicrobial drugs was found. Etiotropic treatment is carried out according to approved schemes (Tables 17-24–17-26).

Table 17-24. Scheme for the use of antibacterial drugs in the treatment of bubonic plague

A drug	Mode of application	Single dose, g	Frequency of application per day	Course duration, days
Doxycycline	Inside	0,2	2	10
Ciprofloxacin	Inside	0,5	2	7–10
Pefloxacin	Inside	0,4	2	7–10
Ofloxacin	Inside	0,4	2	7–10
Gentamicin	V/m	0,16	3	7
Amikacin	V/m	0,5	2	7
Streptomycin	V/m	0,5	2	7
Tobramycin	V/m	0,1	2	7
Ceftriaxone	V/m	2	1	7
Cefotaxime	V/m	2	3–4	7–10
Ceftazidime	V/m	2	2	7–10
Ampicillin/sulbactam	V/m	2/1	3	7–10
Aztreons	V/m	2	3	7–10

Table 17-25. Scheme for the use of antibacterial drugs in the treatment of pneumonic and septic forms of plague

A drug	Mode of application	Single dose, g	Frequency of application per day	Course duration, days
Ciprofloxacin*	Inside	0,75	2	10–14
Pefloxacin*	Inside	0,8	2	10–14
Ofloxacin*	Inside	0,4	2	10–14
Doxycycline*	Inside	0.2 at the 1st appointment, then 0.1 each	2	10–14
Gentamicin	V/m	0,16	3	10
Amikacin	V/m	0,5	3	10
Streptomycin	V/m	0,5	3	10
Ciprofloxacin	IV	0,2	2	7
Ceftriaxone	V/m, i.v.	2	2	7–10
Cefotaxime	V/m, i.v.	3	3	10
Ceftazidime	V/m, i.v.	2	3	10
Chloramphenicol (chloramphenicol sodium succinate**)	V/m, i.v.	25–35 mg/kg	3	7

** Used to treat plague affecting the central nervous system.

Table 17-26. Schemes for the use of combinations of antibacterial drugs in the treatment of pneumonic and septic forms of plague

A drug	Mode of application	Single dose, g	Frequency of application per day	Course duration, days
Ceftriaxone + streptomycin (or amikacin)	V/m, i.v.	1+0,5	2	10
Ceftriaxone + gentamicin	V/m, i.v.	1+0,08	2	10
Ceftriaxone + rifampicin	IV, inside	1+0,3	2	10
Ciprofloxacin* + rifampicin	Inside, inside	0,5+0,3	2	10
Ciprofloxacin + streptomycin (or amikacin)	Inside, intravenously, intramuscularly	0,5+0,5	2	10
Ciprofloxacin + gentamicin	Inside, intravenously, intramuscularly	0,5+0,08	2	10
Ciprofloxacin* + ceftriaxone	IV, IV, IM	0,1–0,2+1	2	10
Rifampicin + gentamicin	Inside, intravenously, intramuscularly	0,3+0,08	2	10
Rifampicin + streptomycin (or amikacin)	Inside, intravenously, intramuscularly	0,3+0,5	2	10

* There are injection forms of the drug for parenteral administration.

In severe cases, it is recommended to use it during the first four days diseases of compatible combinations of antibacterial agents in the doses indicated in the regimens. In the following days, treatment is continued with one drug. For the first 2–3 days, the medications are administered parenterally, and subsequently switch to oral administration.

Along with specific treatment, pathogenetic treatment is carried out aimed at combating acidosis, cardiovascular failure and DN, microcirculation disorders, cerebral edema, and hemorrhagic syndrome.

Detoxification therapy consists of intravenous infusions of colloidal (reopolyglucin, plasma) and crystalloid solutions (glucose 5–10%, polyionic solutions) up to 40–50 ml/kg per day. The previously used anti-plague serum and specific gamma globulin turned out to be ineffective during the observation process, and at present they are not used in practice, nor is the plague bacteriophage used. Patients are discharged after complete recovery (for the bubonic form no earlier than the 4th week, for the pulmonary form - no earlier than the 6th week from the day of clinical recovery) and a three-fold negative result obtained after culture of bubo punctate, sputum or blood, which is carried out on 2- th, 4th, 6th days after cessation of treatment. After discharge, medical observation is carried out for 3 months.

1. Symptoms of bubonic plague
2. Diagnosis of bubonic plague
3. Photo of bubonic plague

Bubonic plague is a group of plagues spread by the bacteria Yersinia pestis, which is carried by rodents through fleas. A terrible acutely infectious disease, has a high mortality rate and is spreading epidemically. It is characterized by a very serious condition, accompanied by inflammatory processes in the lymph nodes.

Symptoms of bubonic plague

The incubation period lasts 2-3 days if they did not receive immunoglobulin before infection, but if a person received immunotherapy before infection, the incubation period can last up to a week. When bitten by an insect (flea), a red spot is observed at this place, which subsequently fills with blood and pus, then this swollen place bursts and an ulcer forms.

Main symptoms:

• Increased body temperature
• Enlarged and dense lymph nodes are located in groups - buboes
• Severe headaches
• Nausea and vomiting
• Powerlessness
• Dizziness
• Insomnia
• Hallucinations
• Tachycardia
• Low blood pressure
• White thick coating on the tongue

When these compacted buboes (dense lymph nodes) are felt, they cause pain. At the beginning of the infection, the symptoms are very pronounced, the face is pale, and the conjunctiva is red; this phenomenon is called the “scared plague face” - facies pestica.

Diagnosis of bubonic plague

For diagnosis, bubo juice is inoculated on blood agar by puncture. They take general tests including seed tank. Based on the clinical history and biological studies of the patient, a diagnosis is made.

If you do not resort to immediate treatment, there is a high probability of death. When using antibiotic therapy, intoxication appears, then improvement gradually appears, but in some cases suppuration may occur in the lymph nodes.

Prevention and treatment of bubonic plague

It is necessary to isolate the patient as soon as possible and begin treatment in a hospital, as well as isolate and examine persons who were in contact with him. The attending physicians are dressed in special uniforms, so-called anti-plague clothing, so that they do not become infected. Where the patient who exposed himself to bubonic plague lived, it is necessary to carry out disinfection. A quarantine is imposed on the locality.

If immediate assistance is not provided, the patient dies.

Pictures and photos of the bubonic plague

Plague (“Black Death”, Pestis) is a particularly dangerous, acute, naturally focal zoonotic* bacterial infection, with multiple routes of transmission, and characterized by a feverish-intoxication syndrome, as well as predominant damage to the skin and lungs.

A brief historical sketch: without exaggeration, one can add to the following characteristics the prefix “most” is the oldest, most dangerous to this day, breaking records for the severity of the disease and the highest mortality rate, as well as for the level of contagiousness (infectiousness) - in all these points, the plague has practically no equal.
The still completely illiterate natives passed on their everyday experience from generation to generation: when dead rats appeared in a hut, the entire tribe left the area, imposing a taboo and never returning.

The 3 largest plague pandemics have been recorded in the history of the world:

In the 3rd century there was the first description, in the territories where Libya, Syria, and Egypt are now located.
The pandemic in the 6th century in the Roman Empire until the end of Justinian’s reign is the “Justinian pandemic.” During this period, thanks to the accumulated experience, they began to introduce quarantine for 40 days in order to prevent the spread of infection.
Late 19th century - third pandemic, most common in seaports. Also, this century became a turning point, because during this period the causative agent of the plague itself was discovered by the French scientist Yersin in 1894.

Long before these pandemics, there were many epidemics that are countless... One of the largest was in France, in the 16th century, where one of the most famous psychics, doctors and astrologers lived - Nostradamus. He successfully fought the “Black Death” with the help of herbal medicine, and his recipe has survived to this day: sawdust of young cypress, Florentine iris, cloves, fragrant calamus and woody aloe - rose petals were mixed with all these components and “rose” tablets were made from this mixture pills." Unfortunately, Nostradamus was unable to save his wife and children from the plague...

Many cities where death reigned were burned, and local doctors, trying to help the infected, wore special anti-plague “armor”: a leather cloak to the very toes, a mask with a long nose - various herbs were placed in this nasal section and, when inhaled, heated air caused evaporation of antiseptic substances contained in herbs, the inhaled air was practically sterile. This mask was protected by crystal lenses, rags were stuck in the ears, and the mouth was rubbed with raw garlic.

It would seem that the era of “antibiotics” would forever eliminate the danger of the plague, they thought so for a short time, until the scientist Bacon modeled a genetic mutant of the plague - an antibiotic-resistant strain. Also, vigilance cannot be reduced because there have always been and are natural foci (territorially aggressive). Social upheaval and economic depression are predisposing factors in the spread of this infection.

The causative agent is Yersinia Pestis, it looks like an ovoid rod, G-, has no spores or flagella, but forms a capsule in the body. On nutrient media it gives characteristic growth: on broth agar - plague stalactites, on solid media, the first 10 hours in the form of “broken glass”, after 18 hours in the form of “lace handkerchiefs”, and by 40 hours “adult colonies” are formed.

There are a number of structural characteristics that are components of pathogenicity factors:

Capsule – inhibits the activity of macrophages.
Pili (small villi) - inhibit phagocytosis and cause the penetration of the pathogen into macrophages.
Plasmocoagulase (also coagulase) - leads to plasma coagulation and disruption of the rheological properties of blood.
Neurominidase - ensures adhesion and attachment of the pathogen due to the release of its receptors on the surface.
The specific antigen pH6 is synthesized at a temperature of 36°C and has antiagocyte and cytotoxic activity.
Antigens W and V – ensure the reproduction of the pathogen inside macrophages.
Catalase activity provided by adenylate cyclase suppresses the oxidative burst in macrophages, which reduces their protective ability.
Aminopeptidases – provide proteolysis (cleavage) on the cell surface, inactivation of regulatory proteins and growth factors.
Pesticin is a biologically active component of Y.pestis that inhibits the growth of other representatives of the genus Yersinia (Yersiniosis).
Fibrinolysin - ensures the breakdown of the blood clot, which subsequently aggravates the clotting disorder.
Hyaluronidase - ensures the destruction of intercellular connections, which further facilitates its penetration into the underlying tissues.
Endogenous purines (the role of their presence is not completely clear, but upon breakdown they form uric acid, which is potentially toxic).
Endotoxin is a lipopolysaccharide complex that has toxic and allergenic effects.
Rapid growth at a temperature of 36.7-37°C - this feature, in combination with antiphaocytic factors (listed above), makes the growth and reproduction of the plague pathogen practically unimpeded.
The ability of the pathogen to sorb (accumulate/collect) hemin (derived from heme - the non-protein part of the Fe3+ transporter in the blood) - this property ensures the reproduction of the pathogen in tissues.
Mouse toxin (lethal = C-toxin) – has cardiotoxic (heart damage), hepatotoxic (liver damage) and capillary toxic effects (impairs vascular permeability and causes thrombocytopathies). This factor is manifested by a blockade of the transfer of electrolytes in mitochondria, i.e. blockade of the energy depot.

All pathogenicity (harmfulness) is controlled by genes (there are only 3 of them) - Bacon influenced them by modeling an antibiotic-resistant mutant of the plague and thus warned humanity about a moving threat in conditions of inappropriate and uncontrolled use of antibiotics.

Resistance of the plague pathogen:

Retains in sputum for 10 days;
On linen, clothes and household items stained with mucus - for weeks (90 days);
In water – 90 days;
In buried corpses - up to a year;
In open warm spaces – up to 2 months;
In bubo pus (enlarged lymph node) – 40 days;
In soil - 7 months;
Freezing and thawing, as well as low temperatures, have little effect on the pathogen;

The following are destructive: direct UV radiation and disinfectants cause instant death, at 60°C - death within 30 minutes, at 100°C - instantaneous death.

Plague refers to natural focal infections, that is, there are territorially dangerous zones in epidemic terms; there are 12 of them on the territory of the Russian Federation: in the North Caucasus, Kabardino-Balkaria, Dagestan, Transbaikalia, Tuva, Altai, Kalmykia, Siberia and the Astrakhan region . Globally, natural foci exist on all continents except Australia: Asia, Afghanistan, Mongolia, China, Africa and South America.

In addition to natural focal (natural) zones, synanthropic foci (anthropouric) are also distinguished - urban, port, ship.
Susceptibility is high, without gender or age restrictions.

Causes of plague infection

The source and reservoir (guardian) of infection are rodents, lagomorphs, camels, dogs, cats, sick people. The carrier is a flea, which remains infective for up to a year. The plague microbe multiplies in the digestive tube of fleas and in the front part of it forms a “plague block” - a plug of a huge amount of the pathogen. When bitten, with the reverse flow of blood, some of the bacteria are washed off from this plug - this is how infection occurs.

Routes of infection:

Transmissible (through flea bites);
Contact – through damaged skin and mucous membranes when skinning infected animals, during slaughter and cutting of carcasses, as well as through contact with biological fluids of a sick person;
Contact household – through household items contaminated with biological media of infected animals/humans;
Airborne (through the air, from a patient with pneumonic plague);
Nutritional – when eating contaminated foods.

Plague symptoms

The incubation period is considered from the moment of introduction of the pathogen to the first clinical manifestations; with plague, this period can last from several hours to 12 days. The pathogen more often penetrates through the affected skin or mucous membranes of the digestive/respiratory tract; it is captured by tissue macrophages, and part of the pathogen remains at the entrance gate, and part is transferred by macrophages to regional (nearby) lymph nodes. But as long as the pathogen dominates phagocytosis and suppresses its action, the body does not identify the pathogen as a foreign object. But phagocytosis is not completely suppressed, some of the pathogens die and after death, an exotoxin is released and upon reaching its threshold concentration, clinical manifestations begin.

The period of clinical manifestations always begins acutely, suddenly, with the first symptoms of intoxication in the form of chills, high fever >39°C lasting for 10 days and/or until death, severe weakness, body aches, thirst, nausea, vomiting; cyanotic, with dark circles under the eyes - these changes against the background of an expression of suffering and horror are called the “mask of plague.” The tongue is covered with a thick, white coating - “chalky tongue”. There is a standard pathogenetic symptom complex (that is, due to the specific mechanism of action of the pathogen, 4 standard symptoms are formed in varying degrees of manifestation):

At the site of the entrance gate, a primary focus is formed, which can undergo stages and stop at one of them: spot - papula - vesicle.
Enlargement of regional lymph nodes (formation of a “plague bubo”) to impressive sizes (≈apple) due to the multiplication of the pathogen in it and the formation of an inflammatory-edematous reaction. But it often happens that the process proceeds so lightning fast that death occurs even before the development of the plague bubo.
ITS (infectious-toxic shock) develops as a result of degranulation of neutrophils (NF) and the death of the pathogen with the release of endotoxin. It is characterized by a certain degree of manifestation and the main diagnostic criteria are: changes in the nervous system (state of consciousness) + or ↓t° of the body + hemorrhagic rash (pinpoint rashes in the oropharynx) + hemorrhages in the mucous membranes + peripheral circulatory disorders (coldness, pallor or blue discoloration of the extremities, nasolabial triangle, face) + changes in pulse and blood pressure(↓) + change in intracranial pressure (↓) + formation of renal failure, manifested as a decrease in daily diuresis + change in acid-base status (acid-base status) towards acidosis
DIC syndrome (disseminated intravascular coagulation) is a very serious condition, which is based on disorganization of the coagulation and anticoagulation systems. DIC occurs in parallel with the development of ITS and manifests itself ↓Tr +clotting time + ↓degree of clot contraction + positive procoagulation test.

Clinical forms of the disease:

Localized (cutaneous, bubonic);
generalized (pulmonary, septic).

The forms of the disease are indicated in the order in which the disease can develop in the absence of treatment.

Cutaneous form: tissue changes occur at the site of the entrance gate (one of 4 standard symptoms); in severe or fulminant cases, a phlyctena (blister) filled with serous-hemorrhagic contents, surrounded by an infiltrative zone with hyperemia and edema, may develop. When palpated, this formation is painful, and when opened, an ulcer forms with black necrosis (eschar) at the bottom - hence the name “black death”. This ulcer heals very slowly and always leaves scars after healing and, due to slow healing, secondary bacterial infections often form.

Bubonic form: “Plague bubo” is an enlarged lymph node, either one or several. The increase may be based on size walnut- up to the apple, the skin is shiny and red with a cyanotic tint, the consistency is dense, palpation is painful, it is not fused with the surrounding tissues, the boundaries are clear due to concomitant periadenitis (inflammation of the peri-lymphatic tissues), on the 4th day the bubo softens and fluctuation appears (a feeling of excitement or vibrations when tapping), on the 10th day this lymphatic focus is opened and a fistula with ulceration is formed. This form can lead to both secondary bacterial septic complications and septic plague complications (i.e. plague bacteremia) with the introduction of the plague pathogen into any organs and tissues.

Septic form: characterized by the rapid development of INS and DIC syndrome, multiple hemorrhages on the skin and mucous membranes come to the fore, and bleeding begins in the internal organs. This form can be primary - when a massive dose of the pathogen is ingested, and secondary - when there are secondary bacterial complications.

Pulmonary form the most dangerous in an epidemiological sense. The onset is acute, as in any other form; pulmonary symptoms (due to the melting of the walls of the alveoli) join the 4 standard clinical symptoms and appear at the first stage: a dry cough appears, which after 1-2 days becomes productive - the sputum is initially foamy, glassy , clear and consistency like water, and then becomes purely bloody, with countless amounts of excitability. This form, like the septic one, can be either primary - with aerogenic infections, or secondary - a complication of the other forms listed above.

Diagnosis of plague

1. Analysis of clinical and epidemiological data: in addition to standard clinical manifestations, the place of residence or location is examined this moment and whether this place corresponds to a natural hearth.
2. Laboratory criteria:
- UAC: Lts and Nf with a shift of the formula to the left (i.e. P/i, S/i, etc.), ESR; The increase in neutrophils occurs at the compensatory stage, as soon as the depot is depleted, Nf ↓ (neutropenia).
- evaluate acid-base balance parameters: the amount of bicarbonate, buffer bases, O₂ and oxygen capacity of the blood, etc.
- OAM: proteinuria, hematuria, bacteriuria - all this will only indicate the degree of compensatory reaction and contamination.
- X-ray diagnostics: ↓mediastinal lymph nodes, focal/lobular/pseudolabular pneumonia, RDS (respiratory distress syndrome).
- Lumbar puncture for meningeal symptoms (stiff neck, positive Kering and Brudzinski symptoms), which reveals: 3-digit neutrophilic pleocytosis + [protein] + ↓[glu].
- Examination of bubo punctate / ulcers / carbuncle / sputum / nasopharyngeal smear / blood / urine / feces / cerebrospinal fluid - that is, where the symptoms dominate, and the biological material is sent for bacteriological and bacteriscopic examination - the preliminary result is in an hour, and the final after 12 hours (when plague stalactites appear, this makes the diagnosis indisputable).
- RPHA (passive hemagglutination reaction), RIF, ELISA, RNGA

If plague is suspected, laboratory tests are carried out in anti-plague suits, in specialized laboratory conditions, using specially designated dishes and containers, as well as with the mandatory availability of disinfectants.

Treatment of plague

Treatment is combined with bed rest and gentle nutrition (table A).

1. Etiotropic treatment (directed against the pathogen) - this stage should be started only with one suspicion of plague, without waiting for bacteriological confirmation. For a certain form, different combinations of drugs are used, alternating them with each other, the most successful combinations in this case:
- Ciftriaxone or Ciprofloxacin + streptomycin, or gentamicin, or rifampicin
- Rifampicin + Streptomycin

2. Pathogenetic treatment: combating acidosis, cardiovascular and respiratory failure, ITS and DIC syndrome. During this treatment, colloid solutions (reopolyglucin, plasma) and crystalloid solutions (10% glucose) are administered.
3. Symptomatic therapy as certain dominant symptoms appear.

Complications of the plague

Development of irreversible stages of ITS and DIC, decompensation of organs and systems, secondary bacterial complications, death.

Prevention of plague

Nonspecific: epidemiological surveillance of natural foci; reducing the number of rodents with disinsection; constant monitoring of the population at risk; preparing medical institutions and medical personnel to work with plague patients; prevention of import from other countries.
Specific: annual immunization with live anti-plague vaccine of persons living in risk areas or traveling there; People who come into contact with plague patients, their belongings, or animal corpses are given emergency antibiotic prophylaxis with the same drugs used for treatment.
Post-infectious immunity is believed to be strong and lifelong, but cases of reinfection have been reported.

*National Infectious Disease Guidelines classify plague as a zoonotic disease, meaning one that cannot spread from person to person. But can this be considered legitimate, remembering the epidemic history of Europe in the 14th century, when in 1346-1351, out of a population of 100 million, only 70 million remained? I don’t think this characterization is appropriate, since only those diseases that are transmitted from animals are called “zoonosis.” to animals and humans is an “infectious dead end”, i.e. without the possibility of infecting other people, and “zooanthraponosis” implies infection not only between animals, but also between people.

General practitioner Shabanova I.E.

(Lat. pestis) is an acute natural focal infectious disease of the group of quarantine infections, occurring with an extremely severe general condition, fever, damage to the lymph nodes, lungs and other internal organs, often with the development of sepsis. The disease is also characterized by high mortality.
Plague bacillus under fluorescence microscopy The causative agent is the plague bacillus (lat. Yersinia pestis), discovered in 1894 simultaneously by the Frenchman Yersin and the Japanese Kitasato.
The incubation period lasts from several hours to 3-6 days. The most common forms of plague are bubonic and pneumonic. The mortality rate for bubonic plague ranges from 27 to 95%, for pneumonic plague - almost 100%.
The famous plague epidemics, which claimed millions of lives, left a deep mark on the history of mankind.

Story
Plague is a disease known since ancient times; the first possible information about it comes from the end of the 2nd and beginning of the 3rd centuries AD. The most famous is the so-called “Justinian Plague” (551-580), which originated in the Eastern Roman Empire and swept the entire Middle East. More than 20 million people died from this epidemic. In the 10th century there was a large plague epidemic in Europe, in particular in Poland and Kievan Rus. In 1090, over 10,000 people died from the plague in Kyiv in two weeks. In the 12th century, plague epidemics occurred several times among the Crusaders. In the 13th century there were several plague outbreaks in Poland and Rus'. In the 14th century, a terrible epidemic of the “Black Death”, brought from Eastern China, swept across Europe. In 1348, almost 15 million people died from it, which was a quarter of the entire population of Europe. In 1346 the plague was brought to Crimea, and in 1351 to Poland and Rus'. Subsequently, outbreaks of plague were observed in Russia in 1603, 1654, 1738-1740 and 1769. An epidemic of bubonic plague swept through London in 1664-1665, killing more than 20% of the city's population.
Isolated cases of infection with bubonic plague are still being recorded.
Plague strikes workers at a printing workshop (engraving 1500 g) In the Middle Ages, the spread of the plague was facilitated by the unsanitary conditions that reigned in cities. There was no sewage system, and all the waste flowed right along the streets, which served as an ideal environment for rats to live.
Alberti described Siena as “losing a lot... due to the lack of cesspools. That is why the whole city emits a stench not only during the first and last watch of the night, when vessels with accumulated sewage are poured out of the windows, but also at other times it is disgusting and very polluted.” In addition, in many places, cats were declared the cause of the plague, allegedly being servants of the devil and infecting people. The mass extermination of cats led to an even greater increase in the number of rats. The cause of infection is most often the bites of fleas that previously lived on infected rats.

Plague as a biological weapon
The use of the plague pathogen as a biological weapon has deep historical roots.
In particular, events in ancient China and medieval Europe saw the use of infected animal carcasses (horses and cows) and human bodies by the Huns, Turks and Mongols to contaminate water sources and water supply systems. There are historical reports of cases of ejection of infected material during the siege of some cities.
Ceramic bomb containing plague-infected material - a flea colony During World War II, the Japanese armed forces used elements of biological weapons in the form of a plague agent. Japanese planes carried out a massive drop of specially prepared plague carriers - infected fleas. Special Detachment 731 deliberately infected civilians and prisoners of China, Korea and Manchuria for further medical research and experiments, studying the prospects of biological weapons mass destruction. The group developed a strain of plague that is 60 times more virulent than the original strain of plague, a kind of absolutely effective weapon of mass destruction with natural spread. Various aerial bombs and projectiles have been developed to drop and disperse infected carriers, such as ground bombs, aerosol bombs, and fragmentation projectiles that damage human tissue. Ceramic bombs were popular, taking into account the peculiarities of the use of living organisms - fleas and the need to maintain their activity and viability under discharge conditions, for which special life support conditions were created (in particular, oxygen was pumped in).

Infection
The causative agent of plague is resistant to low temperatures, is well preserved in sputum, but at a temperature of 55°C it dies within 10-15 minutes, and when boiled - almost immediately. It enters the body through the skin (from a flea bite, usually Xenopsylla cheopis), mucous membranes of the respiratory tract, digestive tract, and conjunctiva.
Based on the main carrier, natural plague foci are divided into ground squirrels, marmots, gerbils, voles and pikas. In addition to wild rodents, the epizootic process sometimes includes so-called synanthropic rodents (in particular, rats and mice), as well as some wild animals (hares, foxes) that are the object of hunting. Among domestic animals, camels suffer from the plague.
In a natural outbreak, infection usually occurs through the bite of a flea that previously fed on a sick rodent; the likelihood of infection increases significantly when synanthropic rodents are included in the epizootic. Infection also occurs during hunting of rodents and their further processing. Massive diseases of people occur when a sick camel is slaughtered, skinned, butchered, or processed. An infected person, depending on the form of the disease, in turn, can transmit plague through airborne droplets or through the bite of certain types of fleas.
The flea xenopsylla cheopis is the main carrier of plague Fleas are a specific carrier of the plague pathogen. This is due to the peculiarities of the digestive system of fleas: just before the stomach, the flea's esophagus forms a thickening - a goiter. When an infected animal (rat) is bitten, the plague bacterium settles in the flea's crop and begins to multiply intensively, completely clogging it. Blood cannot enter the stomach, so
Such a flea is constantly tormented by a feeling of hunger. She moves from owner to owner in the hope of getting her portion of blood and manages to infect enough a large number of people before they die (such fleas live no more than ten days).
When a person is bitten by fleas infected with plague bacteria, a papule or pustule filled with hemorrhagic contents (cutaneous form) may appear at the site of the bite. Then the process spreads through the lymphatic vessels without the manifestation of lymphangitis. The proliferation of bacteria in macrophages of the lymph nodes leads to their sharp increase, fusion and formation of a conglomerate (bubonic form). Further generalization of the infection, which is not strictly necessary, especially in the conditions of modern antibacterial therapy, can lead to the development of a septic form, accompanied by damage to almost all internal organs.
However, from an epidemiological point of view, the most important role is played by the “screening out” of infection into the lung tissue with the development of the pulmonary form of the disease. From the moment plague pneumonia develops, the sick person himself becomes a source of infection, but at the same time, the pulmonary form of the disease is already transmitted from person to person - extremely dangerous, with a very rapid course.

Symptoms
Bubonic form plague is characterized by the appearance of sharply painful conglomerates, most often in the inguinal lymph nodes on one side. The incubation period is 2-6 days (less often 1-12 days). Over the course of several days, the size of the conglomerate increases, and the skin over it may become hyperemic. At the same time, an increase in other groups of lymph nodes appears - secondary buboes. The lymph nodes of the primary focus undergo softening; upon puncture, purulent or hemorrhagic contents are obtained, microscopic analysis of which reveals a large number of gram-negative rods with bipolar staining. In the absence of antibacterial therapy, festering lymph nodes are opened. Then gradual healing of the fistula occurs. The severity of the patients' condition gradually increases by the 4-5th day, the temperature may be elevated, sometimes a high fever immediately appears, but at first the condition of the patients often remains generally satisfactory. This explains the fact that a person sick with bubonic plague can fly from one part of the world to another, considering himself healthy.
However, at any time, the bubonic form of plague can cause generalization of the process and turn into a secondary septic or secondary pulmonary form. In these cases, the condition of the patients very quickly becomes extremely serious. Symptoms of intoxication increase by the hour. The temperature after severe chills rises to high febrile levels. All signs of sepsis are noted: muscle pain, severe weakness, headache, dizziness, congestion of consciousness, up to its loss, sometimes agitation (the patient rushes about in bed), insomnia. With the development of pneumonia, cyanosis increases, a cough appears with the release of foamy, bloody sputum containing a huge amount of plague bacilli. It is this sputum that becomes the source of infection from person to person with the development of the now primary pneumonic plague.
Septic and pulmonary forms of plague occur, like any severe sepsis, with manifestations of disseminated intravascular coagulation syndrome: minor hemorrhages on the skin are possible, bleeding from the gastrointestinal tract is possible (vomiting of bloody masses, melena), severe tachycardia, rapid and requiring correction (dopamine) drop blood pressure.

Clinical picture
The clinical picture of plague is differentiated depending on the method of infection of the patient. As a rule, the following forms of the disease are distinguished: Local form ( cutaneous, bubonic and cutaneous-bubonic ) - in this form the plague microbe in external environment practically doesn't hit.
Generalized form (primary and secondary septic) with increased dispersion of the microbe into the external environment, primary pulmonary, secondary pulmonary and intestinal with abundant release of the microbe. At the same time, the intestinal form of plague is isolated exclusively as a complication of other forms of this disease and, as a rule, is not present in the classification of forms of the disease. The incubation period of the plague ranges from 72 to 150 hours, in most cases not exceeding three days. In exceptional cases, with a number of forms of the disease, its reduction is possible. A feature of the disease is its development pattern. Signs of the disease appear suddenly, without preliminary symptoms of primary development. As a rule, chills and weakness are not observed, the temperature rises to 39 - 40 degrees occurs suddenly, the patient experiences severe headaches, often attacks of vomiting. Redness (hyperemia) of the face, conjunctiva of the eyelids and eyeball, muscle pain, and a feeling of weakness are recorded. Characteristic signs
diseases: white coating on the surface of the tongue, significantly dilated nostrils, noticeable dry lips. As a rule, there is an increase in the temperature of the skin, its dryness, and a rash may appear, however, in some cases (in particular, with cardiac weakness, the external manifestation of sweat is possible when the patient’s skin is relatively cold). A feature of the plague is the patient’s constant feeling of thirst. The disease is characterized by a high degree of damage to the patient’s central nervous system due to severe intoxication, resulting in insomnia or agitation. In some cases, there is delirium and loss of coordination of movements. The patient is characterized by restlessness, fussiness, and increased mobility. In some cases, indigestion, difficulty urinating and abdominal pain upon direct contact are recorded. As a rule, the patient’s blood will show polynuclear leukocytosis from twenty to fifty thousand with a shift of the blood formula to the left with a slight change in the blood, a normal number of red blood cells and hemoglobin, and accelerated ROE. The death of the patient is caused by severe sepsis and severe toxinemia. The clinical form of the plague is formed not by its symptoms, but, as a rule, by cases of local damage to the patient, namely manifestations of bubonic, septic and, less commonly, pneumonic plague.
Cutaneous plague
Penetration of the plague microbe through the skin does not cause a primary reaction; in only 3% of cases there is redness and thickening of the skin with noticeable pain. At the same time, the primary redness-papule turns into a vesicle and pustule, after which the pain decreases, and then external signs no longer appear. However, the inflammatory process progresses, a carbuncle appears, turning into an ulcer, which, upon healing, forms a scar. In some cases, when the lymph nodes are affected, the bubonic form of plague is recorded.
Cutaneous bubonic plague
The cutaneous bubonic form of plague is fixed when the microbe penetrates through the skin. The plague microbe, which has penetrated under the skin with the flow of lymph, is carried into the patient’s lymph node, causing an inflammatory process that spreads to nearby tissues, creating a so-called bubo, which is quite painful on palpation. At the same time, inflammatory processes are reduced.
Bubonic plague
Bubonic plague The bubonic form of plague is characterized by the absence of a reaction at the site of introduction of the microbe, in contrast to the skin form. Symptoms are found on the patient’s lymph nodes, most often the inguinal and femoral buboes are noticed, less often - the axillary and cervical ones. The first sign of bubonic plague is sharp pain at the site of the developing bubo, which is noted both during movement and at rest. In the primary stage of plague, individual hypertrophied lymph nodes can be palpated at the site of the disease. The bubo is then synthesized with surrounding tissues into unified education, thus being an important sign of bubonic plague. When palpating a single bubo, a tumor is felt, dense only in its center, the location of the lymph nodes. The skin in the area of ​​the bubo acquires red tints, in the center it can turn blue. It is important to note that the size of the bubo characterizes the course of the disease: with a benign course, the bubo develops and reaches the size of a chicken egg or more, the inflammatory phase takes about six to eight days. Then suppuration and resorption occurs, sclerosis of the bubo. On the contrary, in severe cases of plague, the bubo does not develop, the microbe overcomes the boundaries of the lymph nodes, using the flow of lima, spreading throughout the body, which can lead to a fatal outcome without special therapy. Should
It should be noted that the negative process, as a rule, can be avoided by using antibiotics, causing the resorption of the bubo, avoiding the spread of the microbe. Of diagnostic significance is the discrepancy between the body's temperature response and the patient's pulse rate, since the pulse is 140 beats per minute, and arrhythmia is noted. Typically, maximum blood pressure decreases. In critical cases, the maximum pressure is lowered to 90 - 80, the minimum - to 45 - 40. Currently, patients with the bubonic form of plague die extremely rarely, which is achieved by using antibiotics, however, the bubonic form of plague can cause plague pneumonia as a complication, which has an adverse effect during the course of the disease and creates a great danger of spreading the plague microbe by airborne droplets. A separate form of complication is meningitis, which is characterized by severe headache, painful tension in the muscles of the back of the head, damage to the cranial nerves and a positive Kernig sign, convulsions are not excluded. In pregnant women, abortion or premature birth cannot be ruled out.
Septicemic form of plague
Septic form of plague affecting the limbs In the primary septic form of plague, the microbe penetrates the skin or through the mucous membranes, which is associated with the high virulence of the microbe, its massive infectious dose and the low resistance of the patient’s body, which allows the pathogen to penetrate the patient’s blood without any noticeable external changes, overcoming defense mechanisms of the body. The primary sign of the disease is a high temperature of the patient, and the increase is recorded unexpectedly for the patient. Accompanied by shortness of breath, rapid pulse, delirium, weakness, prostration. It is possible that a characteristic rash may appear on the patient’s skin. If left untreated, death occurs within two to four days. In exceptional cases, under negative conditions, a fatal outcome has been observed within 24 hours, the so-called fulminant form of plague,” without any characteristic clinical signs.
Pneumonic plague
The pneumonic form of plague is primary pneumonia and develops when a person is infected by airborne droplets of his respiratory system. The pulmonary form is characterized by the development of foci of inflammation in the lungs as the primary symptoms of plague. There are two stages of pneumonic plague. The first stage is characterized by the predominance of general plague symptoms; in the second stage of the pulmonary form there are sharp changes in the patient’s lungs. In this form of the disease there is a period of febrile excitement, a period at the height of the disease and a terminal period with progressive shortness of breath and coma. The most dangerous period is characterized by the release of microbes into the external environment - the second period of the disease, which has critical epidemic significance. On the first day of illness, a patient with a pneumonic form of plague experiences chills, headaches, pain in the lower back, limbs, weakness, often nausea and vomiting, redness and puffiness of the face, an increase in temperature to 39 - 41 degrees, pain and a feeling of tightness in the chest, difficulty breathing, restlessness, rapid and often arrhythmic pulse. Then, as a rule, rapid breathing and shortness of breath are present. In the agonal period, shallow breathing and pronounced adynamia are observed. A weak cough is recorded, the sputum contains streaks of blood and a significant amount of plague microbes. In this case, occasionally, sputum is absent or has an atypical character. The clinic of plague pneumonia is characterized by a pronounced paucity of objective data in patients, which is not comparable with the objectively serious condition of the patients; changes in the lungs are practically absent or insignificant at all stages of the disease. Wheezing is practically not audible, bronchial breathing is heard only in limited areas. At the same time, patients with the primary pneumonic form of plague without the necessary treatment die within two to three days, while absolute mortality and a rapid course of the disease are characteristic.

Diagnosis
The most important role in diagnosis in modern conditions epidemiological history plays a role. Arrival from zones endemic for plague (Vietnam, Burma, Bolivia, Ecuador, Turkmenistan, Karakalpakstan, etc.), or from anti-plague stations of a patient with the signs of the bubonic form described above or with signs of the most severe - with hemorrhages and bloody sputum - pneumonia with severe lymphadenopathy is a sufficiently serious argument for the doctor of first contact to take all measures to localize the suspected plague and accurately diagnose it. It should be especially emphasized that in the conditions of modern drug prevention, the likelihood of illness among personnel who have been in contact with a coughing plague patient for some time is very small. Currently, there are no cases of primary pneumonic plague (that is, cases of infection from person to person) among medical personnel. An accurate diagnosis must be made using bacteriological studies. The material for them is the punctate of a suppurating lymph node, sputum, the patient’s blood, discharge from fistulas and ulcers.
Laboratory diagnosis is carried out using a fluorescent specific antiserum, which is used to stain smears of discharge from ulcers, punctate lymph nodes, and cultures obtained on blood agar.

Treatment
If plague is suspected, the sanitary and epidemiological station of the area is immediately notified. The notification is filled out by the doctor who suspects an infection, and its forwarding is ensured by the chief physician of the institution where such a patient was found.
The patient should be immediately hospitalized in the infectious diseases hospital. A doctor or paramedical worker of a medical institution, upon discovering a patient or suspected of having the plague, is obliged to stop further admission of patients and prohibit entry and exit from the medical institution. While remaining in the office or ward, the medical worker must inform the chief physician in a way accessible to him about the identification of the patient and demand anti-plague suits and disinfectants.
In cases of receiving a patient with lung damage, before putting on a full anti-plague suit, the medical worker is obliged to treat the mucous membranes of the eyes, mouth and nose with streptomycin solution. If there is no cough, you can limit yourself to treating your hands with a disinfectant solution. After taking measures to separate the sick person from the healthy, a list of persons who had contact with the patient is compiled in a medical institution or at home, indicating the last name, first name, patronymic, age, place of work, profession, home address.
Until the consultant from the anti-plague institution arrives, the health worker remains in the outbreak. The issue of its isolation is decided in each specific case individually. The consultant takes the material for bacteriological examination, after which specific treatment of the patient can begin
antibiotics.
When identifying a patient on a train, plane, ship, airport, railway station, actions medical workers remain the same, although the organizational measures will be different. It is important to emphasize that the separation of a suspicious patient from others should begin immediately after his identification.
The head doctor of the institution, having received a message about the identification of a patient suspected of plague, takes measures to stop communication between the hospital departments and clinic floors, and prohibits leaving the building where the patient was found. At the same time, organizes the transmission of emergency messages to a higher organization and the anti-plague institution. The form of information can be arbitrary with the obligatory presentation of the following data: last name, first name, patronymic, age of the patient, place of residence, profession and place of work, date of detection, time of onset of the disease, objective data, preliminary diagnosis, primary measures taken to localize the outbreak, position and last name the doctor who diagnosed the patient. Along with the information, the manager requests consultants and the necessary assistance.
However, in some situations, it may be more appropriate to carry out hospitalization (before establishing an accurate diagnosis) in the institution where the patient is at the time of the assumption that he has plague. Therapeutic measures are inseparable from the prevention of infection of personnel, who must immediately put on 3-layer gauze masks, shoe covers, a scarf made of 2 layers of gauze that completely covers the hair, and protective glasses to prevent splashes of sputum from entering the mucous membrane of the eyes. According to the rules established in the Russian Federation, personnel must wear an anti-plague suit or use special means of anti-infective protection with similar properties. All personnel who had contact with the patient remain to provide further assistance to him. A special medical post isolates the compartment where the patient and the personnel treating him are located from contact with other people. The isolated compartment should include a toilet and a treatment room. All personnel immediately receive prophylactic antibiotic treatment, continuing throughout the days they spend in isolation.
Treatment of plague should be comprehensive and include the use of etiotropic, pathogenetic and symptomatic agents. Antibiotics of the streptomycin series are most effective for treating plague: streptomycin, dihydrostreptomycin, pasomycin. In this case, streptomycin is most widely used. In the bubonic form of plague, the patient is administered intramuscular streptomycin 3-4 times a day (daily dose of 3 g), tetracycline antibiotics (vibromycin, morphocycline) intravenous at 4 g/day. In case of intoxication, administer intravenously saline solutions, hemodez. A drop in blood pressure in the bubonic form should in itself be regarded as a sign of generalization of the process, a sign of sepsis; in this case, there is a need for resuscitation measures, administration of dopamine, and installation of a permanent catheter. For pneumonic and septic forms of plague, the dose of streptomycin is increased to 4-5 g/day, and tetracycline - to 6 g. For forms resistant to streptomycin, chloramphenicol succinate can be administered up to 6-8 g intravenously. When the condition improves, the dose of antibiotics is reduced: streptomycin - up to 2 g / day until the temperature normalizes, but for at least 3 days, tetracyclines - up to 2 g / day daily orally, chloramphenicol - up to 3 g / day, for a total of 20-25 g. Biseptol is also used with great success in the treatment of plague.
In case of pulmonary, septic form, development of hemorrhage, they immediately begin to relieve disseminated intravascular coagulation syndrome: plasmapheresis is performed (intermittent plasmapheresis in plastic bags can be carried out on any centrifuge with special or air cooling with a capacity of its glasses of 0.5 liters or more) in the volume removed plasma 1-1.5 liters when replaced with the same amount of fresh frozen plasma. In the presence of hemorrhagic syndrome, daily administration of fresh frozen plasma should not be less than 2 liters. Until the acute manifestations of sepsis are stopped, plasmapheresis is carried out daily. The disappearance of signs of hemorrhagic syndrome and stabilization of blood pressure, usually in sepsis, are grounds for stopping plasmapheresis sessions. At the same time, the effect of plasmapheresis in the acute period of the disease is observed almost immediately, signs of intoxication decrease, the need for dopamine to stabilize blood pressure decreases, muscle pain subsides, and shortness of breath decreases.
The team of medical personnel providing treatment to a patient with pneumonic or septic form of plague must include an intensive care specialist.

Current state
Every year, the number of people sick with the plague is about 2.5 thousand people, with no downward trend. For Russia, the situation is complicated by the annual identification of new cases in states neighboring Russia (Kazakhstan, Mongolia, China), and the importation of a specific carrier of the plague, the flea Xenopsylla cheopis, through transport and trade flows from the countries of Southeast Asia.
According to available data, according to the World Health Organization, over the past 15 years, about forty thousand cases have been recorded in 24 countries, with a mortality rate of about seven percent of the number of cases. In a number of countries in Asia (Kazakhstan, China, Mongolia and Vietnam), Africa (Tanzania and Madagascar), and the Western Hemisphere (USA, Peru), cases of human infection are recorded almost every year.
Over the past 5 years, 752 strains of the plague pathogen have been recorded in Russia. At the moment, the most active natural foci are located in the territories of the Astrakhan region, the Kabardino-Balkarian and Karachay-Cherkess republics, the republics of Altai, Dagestan, Kalmykia, and Tyva. Of particular concern is the lack of systematic monitoring of the activity of outbreaks located in the Ingush and Chechen Republics.
At the same time, no cases of plague have been recorded on the territory of Russia since 1979, although every year in the territory of natural foci (with a total area of ​​more than 253 thousand sq. km) over 20 thousand people are at risk of infection.
At the same time, in 2001 - 2003, 7 cases of plague were registered in the Republic of Kazakhstan (with one death), in Mongolia - 23 (3 deaths), in China in 2001 - 2002, 109 people fell ill (9 deaths) . Forecast of epizootic and epidemic situation in neighboring countries Russian Federation natural foci of the Republic of Kazakhstan, China and Mongolia remains unfavorable.

Forecast
Under modern therapy, mortality in the bubonic form does not exceed 5-10%, but in other forms the recovery rate is quite high if treatment is started early. In some cases, a transient septic form of the disease is possible, which is difficult to diagnose and treat.
(“fulminant form of plague”).

Famous people who died from the plague Simeon the Proud Among famous people who died from the plague can be called the Russian prince Simeon the Proud - the son of Ivan I Kalita.

A large number of the population of Europe in the 14th century was destroyed by the plague, which is also called the Black Death. These terrible incidents remained forever in people's memory and were immortalized by the works of many artists. After mass deaths, the disease repeatedly claimed the lives of the population of many countries. Even now it is considered especially dangerous. What is the disease bubonic plague, how can a flea enter the body, and what treatment does the patient need?

What is bubonic plague

Why is it called that?

The plague bacterium is transmitted through physical contact and then enters the lymphatic system. Local foci of inflammation form near the lymph nodes and places where the infection has occurred. It looks like compactions that can reach the size of a lemon, then abscesses are possible, transforming them into soft lumps. When opening them you can feel bad smell. Such sources of inflammation are called buboes. This is where the name of this type of plague comes from.

History of the bubonic plague

Over 3 centuries, the plague killed millions of people and destroyed entire cities. Only many years later, scientists identified the causes of the plague epidemic and methods of treating it. The source of the disease was carried by rats, and the population, trying to escape the scourge, locked themselves in their homes. Such actions only aggravated the situation, because the life of that time was not equipped with the necessary sanitary and hygienic means.

Rats were common inhabitants of every home, because the fight against them was unsuccessful. In closed spaces, harmful bacteria spread faster. After the pandemic began, doctors of that time began to come up with a variety of protective measures to ensure personal safety. A uniform consisting of a long black cloak, leather trousers, and a mask with a beak was considered popular and effective.

Historically, there have been three recorded plague pandemics. The first is called the “Justinian Plague,” which destroyed the population of Egypt and the Roman Empire (526-566). The second - the “Black Death” (1346-1351) captured the Crimea, the Mediterranean, and Western Europe. This wave is the largest, claiming more than 50 million lives. The third raged in India and Hong Kong (1895), losses amounted to 12 million people. During this period, major discoveries were made about the sources of disease, which allowed the invention of methods to treat disease and prevent epidemics.

How is it transmitted?

The bacteria are carried by fleas that live on the skin of rodents. The most dangerous rats for humans are all types of rats: gray, red and black. Human infection can occur in various ways. Transmissible infection occurs through the bite of an infected fly. This is possible due to close contact with the animal. This way of infecting a person is through blood. A high risk of infection is observed among people in unsanitary conditions, employees of pet stores, and veterinary clinics.

The plague disease is transmitted through contact and household contact by removing and processing the skins of infected rodents (or camel carcasses). Food method also occurs - for example, you can get the plague by eating foods that are contaminated with plague bacteria. Infection with the plague by airborne droplets occurs through contact with a patient with pneumonic plague.

The bacterium penetrates through a wound on a person’s skin or mucous membranes. Redness or an ulcer may form at the site where the pathogen enters. Through the lymphatic vessels, the bacillus infects the nearest lymph node, which quickly enlarges and becomes inflamed, and begins to multiply there. The entry of the microorganism into the general bloodstream leads to its spread throughout the body, which ensures severe intoxication.

Pathogen

The carrier of such a terrible disease is the plague bacillus, a bacterium belonging to the Enterobacteriaceae family. In order to develop under natural conditions, the plague bacillus had to for a long time adapt. This determines the characteristics of the growth and development of the microorganism, which:

• grows in simple and nutritious areas;
• has a different shape;
• contains more than 35 types of antigens that increase life expectancy;
• resistant to environmental conditions, but dies when boiled;
• has two pathogenicity factors, which can easily provoke a rapid effect on the body;
• unable to resist antibiotics.

Incubation period

Plague pathogens penetrate into circulatory system through the skin, and after they enter the lymph nodes, primary inflammation begins. The incubation period is 3-6 days - this is the time required for the symptoms of the disease to begin to actively manifest. During an epidemic, the time is reduced to 1-2 days. Maximum term incubation is 9 days.

Symptoms

Often, after infection with a bacterium, the bubonic type of disease occurs. The infected person develops a slight redness on the affected area, which quickly develops into a pustule, and after opening, an ulcer appears. A week after communicating with the patient, sudden fever, headache, weakness, chills, swollen lymph nodes, and cough with sputum are observed. These are the consequences of a flea bite. If the infected person does not take treatment measures on time, the infection can spread to other parts of the body.

The skin over the lumps becomes reddish and shiny. After 4 days, the inflammations become softer, and when tapped they move. After opening, fistulas form. From the first day, increased nervousness and severe muscle pain may begin. The following signs are also characteristic of the plague: the patient’s face darkens, circles appear under the eyes, the tongue becomes coated, and the heart rhythm is disturbed. Black plague can be complicated by meningitis.

Diagnostics

The main methods for diagnosing plague are epidemiological information, bacteriological studies, and anamnesis. When examining to identify an infectious plague disease, the juice of the abscess is inoculated. The juice is obtained by two methods: sampling with a syringe, or using a saline solution injected into the inflammation, and secondary sampling of the liquid into a new syringe.

It is imperative to culture the infected person’s secretions, followed by isolating pure plague bacteria from it in the laboratory for more detailed study. When diagnosing plague, it is important to understand its distinctive features from tularemia (its ulcerative-bubonic type). They lie in the fact that with tularemia there is no pain when palpating the affected lymph nodes.

Treatment of bubonic plague

Treatment of plague disease is carried out exclusively in specialized hospitals, or, if necessary, in temporarily organized hospitals. During treatment, it is necessary to disinfect the secretions of the infected person. All objects with which there was interaction are necessarily subjected to special treatment. Personnel carry out all actions only if they have special protective suits. The most effective drugs prescribed for major cases of plague are tetracycline, administered orally, and streptomycin, administered intramuscularly.

Cure for the Plague

Plague bubo is treated with antibiotics. They are used intramuscularly and inside inflammations. In addition to them, the patient is prescribed symptomatic therapy, which helps to cope with other manifestations of the consequences of a terrible infection. The patient continues to recover successfully after three negative bacteriological culture results. Then, after a month in the hospital, the patient is discharged, and he is registered with an infectious disease specialist for another 3 months.

Prevention

A mandatory requirement when identifying a virus is the isolation of a plague patient from other people. Persons who have been in contact with the patient are isolated. Septic treatment of the place of residence is carried out, a quarantine is imposed on the locality, and people are immunized with a vaccine. For prevention, the number of rodents is also constantly monitored and pest control work is carried out according to a strict scheme.

Plague in our time

Today, this disease can be found in Iran, Nepal, Brazil, and Mauritania. There were no recorded cases of plague in our country until the 70s of the 20th century, but the possibility of an outbreak of an epidemic exists and worries many. The last cases of plague were recorded in 2009 in China, and 4 years later in Kyrgyzstan.

Photos of people sick with plague

Video