Doctors Revision

Infectious Diseases

Plague

Severe acute bacterial infection caused by Yersinia pestis, transmitted primarily by infected rodent fleas. Can cause rapidly fatal illness. A notifiable disease.

Open in the interactive guide
On this page

Referral and warning signs

When to refer

IMMEDIATE URGENT REFERRAL/ADMISSION to Hospital (H/RR) for ALL suspected cases of plague.

Red flags

  • Acute fever + Painful swollen lymph node (bubo).
  • Signs of sepsis/shock.
  • Cough with bloody sputum / Respiratory distress (pneumonic plague).
  • Exposure history in endemic area or contact with known case/rodents.

Signs and symptoms

  • Bubonic Plague (Most common form):
  • - Sudden onset of fever, chills, headache, severe malaise, weakness.
  • - Painful, swollen lymph node(s) called a 'bubo', typically in groin, axilla, or neck near site of flea bite.
  • - Bubo is tense, tender, may suppurate later.
  • - Without treatment, bacteria spread -> Septicaemic plague.
  • Septicaemic Plague:
  • - Bacteria multiply in bloodstream.
  • - Fever, chills, extreme weakness, prostration, shock.
  • - Abdominal pain, nausea, vomiting, diarrhoea.
  • - Bleeding manifestations (DIC), purpura, gangrene of extremities ('Black Death').
  • - May occur primarily or secondary to bubonic plague.
  • Pneumonic Plague:
  • - Infection localized to lungs.
  • - Sudden onset fever, headache, malaise.
  • - Cough with production of watery, bloody, or purulent sputum (highly infectious).
  • - Chest pain, dyspnoea.
  • - Rapidly progressive respiratory failure and shock.
  • - Develops from inhaling infectious droplets (primary) or haematogenous spread from bubonic/septicaemic form (secondary).
  • - Highly contagious person-to-person.
  • - Usually fatal within 1-3 days if untreated.

Risk factors

  • Living in or travelling to plague-endemic areas (often associated with wild rodents).
  • Contact with infected rodents (rats, squirrels, prairie dogs) or their fleas.
  • Handling tissues or fluids of infected animals (hunters, veterinarians).
  • Close contact (<2 meters) with a patient with pneumonic plague.
  • Bioterrorism event.

Diagnosis

Clinical assessment

High index of suspicion based on acute febrile illness with painful bubo OR sepsis/shock OR severe pneumonia, especially with relevant geographic exposure or rodent/flea contact.

Differential diagnosis

  • Other causes of lymphadenopathy (Staph/Strep adenitis, Tularemia, Cat Scratch Disease, Lymphoma, TB).
  • Other causes of sepsis/shock.
  • Other causes of severe pneumonia.
  • Viral Haemorrhagic Fevers.
  • Anthrax, Typhoid, Malaria.

Investigations

  • Specimen Collection (Use strict infection control precautions!):
  • - Bubo Aspirate: Gram stain (Gram-negative coccobacilli, bipolar 'safety pin' staining), Culture, PCR.
  • - Blood Cultures: For septicaemic plague.
  • - Sputum: Gram stain, Culture, PCR (for pneumonic plague).
  • - Serology (antibody detection): Useful retrospectively.
  • FBC (leukocytosis), Coagulation studies (DIC).

Diagnostic criteria

Clinical suspicion + Epidemiological link +/- Laboratory confirmation (Gram stain, culture, PCR, serology).

Management

Non-pharmacological management

  • Urgent Hospital Admission.
  • Isolation Precautions:
  • - Standard + Contact precautions for ALL forms.
  • - Droplet precautions ADDED for Pneumonic plague (continue for 48-72h after effective antibiotics started and clinical improvement).
  • Supportive Care: IV fluids, oxygen, vasopressors for shock, respiratory support (ventilation) for pneumonic plague.
  • Drainage of fluctuant buboes (usually after several days of antibiotics).

Pharmacological treatment

  • Prompt Antibiotic Therapy (Start empirically based on suspicion):
  • - First line (Aminoglycosides): Gentamicin 5-7 mg/kg IV/IM daily (or divided Q8H: 1.7mg/kg) for 7-10 days. OR Streptomycin 1g IM Q12H. (LOC: HC4/H)
  • - Alternative (Fluoroquinolones): Ciprofloxacin 400mg IV Q8-12H or 500-750mg PO Q12H. Levofloxacin.
  • - Alternative: Doxycycline 100mg IV/PO Q12H (Child >8y: 2mg/kg/dose). (LOC: HC2+)
  • - Alternative: Chloramphenicol 500mg IV/PO Q6H (Child: 25mg/kg/dose). Good CNS penetration, use if meningitis suspected. (LOC: HC4)
  • - Duration: Typically 10-14 days, or until afebrile for 2 days.

Monitoring

Monitor clinical response (fever, bubo size, respiratory status, haemodynamics). Monitor antibiotic levels/renal function if using aminoglycosides.

Complications

  • Septic shock, DIC.
  • Respiratory failure / ARDS (pneumonic plague).
  • Meningitis.
  • Gangrene.
  • Suppurative buboes.
  • High mortality if treatment delayed.

Prevention

  • Rodent and flea control in endemic areas.
  • Avoid contact with sick or dead rodents/animals.
  • Use insect repellent in endemic areas.
  • Wear gloves when handling potentially infected animals.
  • Prophylaxis for close contacts of pneumonic plague cases (Doxycycline or Ciprofloxacin for 7 days).
  • Isolation of patients (esp. pneumonic).
  • Health education.
  • Vaccine (limited availability/efficacy, not routinely recommended).

Patient education

  • Explanation of the serious bacterial infection.
  • Mode of transmission (fleas, rodents, respiratory droplets for pneumonic).
  • Need for urgent hospitalization, isolation (if pneumonic), and antibiotics.
  • Importance of identifying and managing contacts (if pneumonic).
  • Prevention measures.

Uganda-specific notes

Plague occurs in specific endemic foci in Uganda (e.g., West Nile, Nebbi, Arua). Requires high index of suspicion in patients from these areas with compatible symptoms. Prompt notification of District Health Team essential. Gentamicin/Doxycycline often used.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 2, Section 2.1.6

Scroll to Top