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On July 8, 2014, the Colorado Department of Public Health and Environment (CDPHE) laboratory identified Yersinia pestis, the bacterium that causes plague, in a blood specimen collected from a man (patient A) hospitalized with pneumonia. The organism had been previously misidentified as Pseudomonas luteola by an automated system in the hospital laboratory. An investigation led by Tri-County Health Department (TCHD) revealed that patient A's dog had died recently with hemoptysis. Three other persons who had contact with the dog, one of whom also had contact with patient A, were ill with fever and respiratory symptoms, including two with radiographic evidence of pneumonia. Specimens from the dog and all three human contacts yielded evidence of acute Y. pestis infection. One of the pneumonia cases might have resulted through human-to-human transmission from patient A, which would be the first such event reported in the United States since 1924.
This outbreak highlights the need to consider plague in the differential diagnosis of ill domestic animals, including dogs, in areas where plague is endemic; the limitations of automated diagnostic systems for identifying rare bacteria such as Y. pestis; and the potential for milder plague illness in patients taking antimicrobial agents. Hospital laboratorians should be aware of the limitations of automated identification systems, and clinicians should suspect plague in patients with clinically compatible symptoms from whom P. luteola is isolated.
Patient A, a previously healthy middle-aged man, developed fever and cough on June 28. Over the next 24 hours his condition worsened with increasing cough and the production of bloody sputum. He was admitted to a local hospital where he was diagnosed with pneumonia (Figure). Blood cultures collected on June 30 grew a gram-negative rod that was initially identified as P. luteola using an automated identification system. Over the next 6 days patient A's respiratory status deteriorated, and he was transferred to another facility where he required intubation. Because of the severity of his illness and previous reports of misidentification of Y. pestis as P. luteola, the isolate was sent to the CDPHE laboratory for further testing. On July 8 the specimen was correctly identified as Y. pestis, and patient A received a diagnosis of pneumonic plague. Patient A was treated with broad-spectrum antibiotics, including levofloxacin and streptomycin, and recovered after hospitalization for 23 days.
TCHD initiated an investigation, consisting of interviews with patient A's family, evaluation of potential exposures to the patient, and an environmental assessment to determine the risk for further disease transmission. The investigation revealed that patient A's dog, a male American pit bull terrier aged 2 years, became ill with fever, jaw rigidity, drooling, and right forelimb ataxia on June 24 (Table). The dog was kept overnight at a veterinary clinic and humanely euthanized the following day after developing dyspnea and bloody sputum. Patient A had close contact with the dog during euthanasia. Necropsy revealed gastric and pulmonary hemorrhage. Samples tested negative for evidence of rabies virus infection and anticoagulants; histopathologic examination of the tissues was declined by patient A. Following patient A's diagnosis with plague, liver and lung tissues from the dog were tested for Y. pestis, and results were positive by both polymerase chain reaction assay and culture. Archived formalin-fixed tissues from the dog were processed for histopathology, revealing severe acute bronchopneumonia with intra-alveolar bacteria. The investigation also identified three other persons who had been in close contact with the ill dog, one of whom who also had contact with patient A. All three subsequently received diagnoses of plague, and all three recovered.
On June 30, two days after patient A became ill, patient B, a female veterinary clinic employee, developed a fever and cough and visited an urgent care facility, where bronchitis was diagnosed. She reported close contact with the ill dog June 24-25. After her symptoms failed to improve with self-initiated amoxicillin/clavulanic acid, patient B visited an emergency department on July 5, received a diagnosis of pneumonia, and was treated with azithromycin, with improvement over the next several days. After notification on July 10 of her exposure to plague, she visited a healthcare provider and was treated with oral levofloxacin. A polymerase chain reaction test on a sputum specimen was positive for Y. pestis. Subsequent testing of paired acute and convalescent serum specimens demonstrated a fourfold increase in antibody titers to Y. pestis, indicative of recent infection.
Patient C, a female veterinary clinic employee, also had close contact with the dog June 24–25 and self-initiated a six-day course of oral doxycycline on June 25. On July 4, she experienced fever, chills, myalgia, and fatigue; symptoms progressed to chest tightness and cough. Following notification of the exposure to plague on July 9, patient C self-initiated a second course of doxycycline and was medically evaluated later that day. Crackles were heard during chest auscultation; however, results of a chest radiograph were normal. A full course of oral doxycycline was continued with resolution of symptoms. Initial and follow-up serum specimens tested positive for antibody to Y. pestis, with a greater than fourfold decrease in antibody titers at follow-up six months later.
On July 4, patient D, a woman who was a close contact of patient A, experienced chest tightness, dyspnea, and fever. She was evaluated at an emergency department, received a diagnosis of pneumonia, and was treated with oral levofloxacin. Patient D handled the body of the dog on June 25 after it died, at one point getting blood on her hands. She also had extended close contact with patient A June 29–30 while he was coughing bloody sputum. On July 8, after patient A was identified with pneumonic plague, patient D was hospitalized and treated with levofloxacin and streptomycin. Paired acute and convalescent serum specimens for patient D demonstrated a greater than fourfold increase in antibody titers to Y. pestis.
TCHD evaluated potential exposures from each patient and conducted an environmental assessment to determine the risk for further disease transmission. Case status was assigned according to case definitions developed by the Council of State and Territorial Epidemiologists for CDC's National Notifiable Diseases Surveillance System.
Medical personnel and personal contacts of all four patients were notified of their possible exposure to plague. A total of 114 persons had close contact with the dog or one or more of the human patients: 36 in veterinary settings, 58 in human health care settings, and 20 as close personal contacts. Antimicrobial prophylaxis was recommended for 88 persons interviewed within 7 days of exposure. The remaining 26 were advised to monitor for fever for seven days and to seek medical attention immediately if symptoms occurred.
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Reference: Runfola JK, et al. Outbreak of Human Pneumonic Plague with Dog-to-Human and Possible Human-to-Human Transmission - Colorado, June–July 2014. MMWR, May 1, 2015:64(16);429-434.