Yersinia pestis infection differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]; Alison Leibowitz [3]

Overview

The differential diagnosis for yersina pestis infection is dependent on the clinical syndrome (bubonic plague, septicimic plague, pneumonic plague, or pharyngeal plague). Bubonic plague should be differentiated from other causes of lymphadenopathy, such as streptococcal or staphylococcal lymphadenitis, infectious mononucleosis, cat-scratch fever, and tularemia. Septicemic plague should be differentiated from non-specific sepsis syndrome and gram negative sepsis. The differential diagnosis for pneumonic plague includes infections that cause community-acquired pneumonia, such as pneumococcal or streptococcal pneumonia, viral pneumonia, hemophilus influenzae, and anthrax.

Differential Diagnosis

Bubonic Plague

Conditions that also cause lymphadenopathy:

• Streptococcal or staphylococcal lymphadenitis
• Infectious mononucleosis
• Cat-scratch fever
• Lymphatic filariasis
• Tick typhus
• Tularemia

Conditions that also cause intra-abdominal lymphadenopathy:

• Appendicitis
• Acute cholecystitis
• Enterocolitis

Condition that also causes inguinal lymphadenopathy:

• Inguinal hernia

Septicemic Plague

Conditions that manifest similarly:

• Non-specific sepsis syndrome
• Gram negative sepsis

Pneumonic Plague

Pneumonic plague should be differentiated from the following diseases:

• Inhalational anthrax (Bacillus anthracis)
  • Widened mediastinum and pleural effusions seen on CXR or chest CT
  • Not true pneumonia; minimal sputum production
  • Hemoptysis uncommon (if present, suggests diagnosis of plague)

• Tularemia (Francisella tularensis)
  • Clinical course not as rapid or fulminant as in pneumonic plague

• Mycoplasmal pneumonia (Mycoplasma pneumoniae)
  • Rarely as fulminant as pneumonic plague

• Pneumonia caused by Chlamydia pneumoniae
  • Rarely as fulminant as pneumonic plague

• Legionnaires' disease (Legionella pneumophila or other Legionella species)
  • Rarely as fulminant as pneumonic plague
  • Community outbreaks of Legionnaires' disease often involve exposure to cooling systems
  • Legionellosis and many other diseases caused by bacterial agents (S aureus, S pneumoniae, H influenzae, K pneumoniae, M catarrhalis) usually occur in persons with underlying pulmonary or other disease or in the elderly

• Psittacosis (Chlamydia psittaci)
  • Rarely as fulminant as pneumonic plague
  • Result of bird exposure

• Other bacterial agents (e.g., Staphyloccocus aureus, Streptococcus pneumoniae, Haemophilus influenzae, Klebsiella pneumoniae, Moraxella catarrhalis)
  • Rarely as fulminant as pneumonic plague
  • Usually occur in persons with underlying pulmonary or other disease or in the elderly

• Influenza
  • Influenza generally seasonal (October-March in United States) or involves history of recent cruise ship travel or travel to tropics

• Hantavirus
  • Exposure to excrement (urine or feces) of mice with Hantavirus

• RSV
  • RSV usually occurs in children (although may be cause of pneumonia in elderly); tends to be seasonal (winter/spring)

• CMV
  • CMV usually occurs in immunocompromised patients

• Q fever (Coxiella burnetii)
  • Exposure to infected parturient cats, cattle, sheep, goats
  • Severe pneumonia not prominent feature

• Leptospirosis

• Hantavirus pulmonary syndrome

• viral pneumonia

References

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