Information on Anthrax and other diseases.

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General Information Concerning Potential Bio-Terrorism Infectious Organisms

Disease	Signs & Symptoms	Physical Exam	Clinical Tests	Key Differential Diagnosis	Incubation Period	Duration of Illness
Anthrax	Fever, malaise, cough, mild chest discomfort, possible short recovery phase then onset of dyspnea, diaphoresis, stridor, cyanosis, shock. Death 24-36 hours after onset of severe symptoms, Hemorrhagic meningitis in up to 50%	Non-specific physical findings.	serology, gram stain, culture, polymerase chain reaction (PCR); CXR - widened mediastinum. Rarely pneumonia.	Hantavirus pulmonary syndrome (HPS), Dissecting aortic aneurysm (no fever)	1-6 days (up to 45 days)	3-5 days
Pneumonic Plague	High fever, chills, headache, hemoptysis, and toxemia, rapid progressionto dyspena, stridor, and cyanosis. Death from respiratory failure, shock, and bleeding.	Rales, hemoptysis, purpura	Gram stain, culture, serum immunoassay for capsular antigen, PCR, immunohistochemical stains (IHC)	HPS, TB, community acquired pneumonia (CAP), meningococcemia ricketiisioses.	2-3 days	1-6 days
Tularemia	Typhodial - aerosal , gastrointestinal & intradermal challenge. Fever, headache, malaise, chest discomfort, anorexia, non-productive cough. Pneumonia in 30 - 80%. Oculoglandular from inoculation of conjuctiva with periorbital edema.	No adenopathy with typhoidal illness.	Serology, culture, PCR, IHC; CXR - pneumonia, mediastinal lymphadenopathy, or pleural effusion.	Atypical CAP, Q fever, Brucellosis.	1 - 10 days (average 3 - 5 days)	2 weeks
Smallpox	Fever, back pain, vomitting, malaise, headache, rigors. Papules 2 - 3 days later, progressing to pulsar vesticles. Abundant on face and extremities initially.	Papules, pustules, or scabs of similar stage, may on face/extremities, palm/soles.	Guamieri bodies on Giemsa or modified silver stain, virons on electorn microscopy, PCR, viral isolation, IHC.	Varicella, vaccinia, monkeypox, cowpox, disseminated herpes zoster.	7 - 17 days (average 12 days)	4 weeks
Botulism	Ptosis, blurred vision, diplopia, generalized weakness, dizziness, dysarthria, dysphonia, dysphagia, followed by symmetrical descending flaccid paralysis and respiratory failure.	No fever, patient alert, postural hypotension, pupils unreactive, normal sensation, variable muscle weakness.	Serology, toxin assays/anaerobic cultures of blood/stool; electromyography studies.	Gullian Barre', myasthenis gravis, tick paralysis, Mg++ intoxication, organophosphate poisoning, polio.	1 - 5 days	Death 24 - 72 hours or respiratory support for months.
Filoviruses (Marburg, Ebola)	Fever, severe headache, malaise, myalgia, maculopapular rash day 5; progression to pharyngitis, hematemesis, melena, uncontrolled bleeding; shock/death days 6 - 9.	Petechia, ecchymoses, conjunctivitis, uncontrolled bleeding.	Serology, viral isolation, PCR, IHC; leukopenia, thrombocytopenia, proteinuria.	Meningococemia, malaria, typhus, leptospirosis, borellosis, thrombotic thrombocytopenic purpura (TTP), rickettsiosis, hemolytic unremic syndrome (HUS), arenaviruses.	2 - 19 days (average 4 - 10 days)	Days to weeks
Arena Viruses (i.e. Lassa)	Fever, malaise, myalgia, headache, N/V, pharyngitis, cough retrosternal pain, bleeding, tremors of toungue and hands, shock, aseptic meningitis, coma, hearing loss in some.	Conjunctivitis, petechia, ecchymoses, flushing over head and upper torso.	Serology, viral isolation, PCR, IHC; leukopenia, thrombocytopenia, proteinuria.	Leptospirosis, meningoccocemia, malaria, typhus, borrelliosis, rickettsiosis, TTP, HUS, filoviruses.	5 - 21 days	7 - 15 days

Pharmacy Prophylaxis and Treatment

Disease	Chemotherapy*	Chemoprophylaxis	Vaccine**	Comments
Anthrax	Ciprofloxacin 400 mg IV q 8-12 h Doxycycline 200 mg IV, then 100 mg IV q 8-12 h Penicillin 2 million units IV q 2 h (see comments)	Ciprofloxacin 500 mg PO bid x 4 wk if unvaccinated, begin initial doses of vaccine (levofloxacin 500 mg qd or ofloxacin 400 mg bid may be used as alternatives) Doxycycline 100 mg PO bid x 4 wk plus vaccination	Bioport vaccine (licensed) 0.5 mL SC @ 0, 2, 4 wk, 6, 12, 18 mo then annual boosters Routinely administered to military personnel; Not routinely available for the civilian population.	Potential alternates for Rx: gentamicin, erythromycin, and chloramphenicol PCN once organisms are shown to be sensitive
Cholera	Oral rehydration therapy during period of high fluid loss Tetracycline 500 mg q 6 h x 3 d Doxycycline 300 mg once, or 100 mg q 12 h x 3 d Ciprofloxacin 500 mg q 12 h x 3 d Norfloxacin 400 mg q 12 h x 3 d (NOT ON FORMULAR)		Wyeth-Ayerst Vaccine 2 doses 0.5 mL IM or SC @ 0, 7-30 days, then boosters Q 6 months	Vaccine not recommended for routine protection in endemic areas (50% efficacy, short term) Alternate Rx: erythromycin, trimethoprim and sulfamethoxazole, and furazolidone Quinolones for tetra/doxy resistant strains
Q Fever	Tetracycline 500 mg PO q 6 h x 5-7 d Doxtcycline 100 mg PO q 12 h x 5-7 d	Tetracycline start 8-12 d post-exposure x 5 d Doxycycline start 8-12 d post-exposure x 5 d	IND 610 - inactivated whole cell vaccine given as single 0.5 ml sc. injection	Currently testing vaccine to determine the necessity of skin testing prior to use.
Plaque	Streptomycin 30 mg/kg/d IM in 2 divided doses x 10 d (or gentamicin) Doxycycline 200 mg IV then 100 mg IV bid x 10-14 d Chloramphenicol 1 gm IV qid x 10-14 d	Doxycycline 100 mg PO bid x 7 d or duration of exposure Ciproflaxin 500 mg PO bid x 7 d	Greer Lab - inactivated vaccine (FDA licensed): 1.0 mL IM; 0.2 mL IM 1-3 mo later; 0.2 mL 5-6 mo after dose 2; 0.2 mL boosters @ 6, 12, 18 mo after dose 3 then q 1-2 years. Prevents bubonic plaque but probably not pneumonic plaque	Plaque vaccine not protective against aerisol challenge in animal studies Alternative Rx: trimethoprim-sulfamethoxazole: Chloramphenicol for plaque meningitis
Tularemia	Streptomycin 30 mg/kg IM divided BID x 10-14 d Gentamicin 3-5 mg/kg/d IV x 10-14 d	Doxycycline 100 mg PO bid x 14 d Tetracycline 500 mg PO QID 14 d	IND - Live attenuated vaccine: one dose by scarification
Brucellosis	Doxycycline 200 mg/d PO plus rifampin 600-900 mg/d PO x 6 wk Ofloxacin 400/rifampin 600 mg/d PO x 6 wks	Doxycycline and rifampin x 3 wk	No human vaccine available	Trimethoprim-sulfamethoxazole may be substituted for rifampin; however, relapse may reach 30%
Viral Hemorrhagic Fevers	Ribavirin (CCHF/arenaviruses) 30 mg/kg IV initial dose; 15 mg/kg IV q 6 h x 4 d; 7.5 mg/kg IV q 8 h x 6 d Passive antibody for AHF, BHF, Lassa fever, and CCHF	N/A	AHF Candid #1 vaccine (x-protection for BHF)(IND) RVF inactivated vaccine (IND)	Aggressive supportive care and management of hypotension very important
Smallpox	Ribavirin (inhaled or oral) Cidofivor The therapy above has been shown to be effective in vitro but clinical experience is lacking	Vaccinia immune globulin (VIG) 0.6 mL/kg IM (within 3 d of exposure, best within 24 h) VIG is maintained at SAMRID 301-619-2833	Wyeth calf lymph vaccinia vaccine (licensed): 1 dose by scarification Not commercially available. CDC has several million doses on reserve.	Pre and post exposure vaccination reccomended if > 3 years since last vaccine.
Botulism	DOD heptavalent equine despeciated antitoxin for serotypes A-G (IND): 1 vial (10 mL) IV; CDC trivalent equine antitoxin for serotypes A,B, E (licensed)		DOD pentavalent toxoid for serotypes A-E (IND): 0.5 ml deep SC @ 0, 2 & 12 wk, then yearly boosters	Skin test for hypersensitivity before equine antitoxin administration.

* Preference of the chemotherapeutic regimen will be based on availability of the listed drugs.
** Most of the vaccine are still investigational (noted as IND) or supply is restricted to a specific group such as the Department of Defense (DOD, or the Center for Disease Control (CDC).