Yersinia pestis infection laboratory findings

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Yazan Daaboul; Serge Korjian

Overview

Bubonic plague is diagnosed by gram stain and culture of aspirated material from suppurative lymph nodes.[1] Collection of blood specimens, lymph node aspirates from buboes, sputum samples, and tracheal swabs are needed before the administration of antibiotics. Additionally, cerebrospinal fluid (CSF) collection is required in cases suspected to have meningeal complications of plague.[2] In the United States, reporting of suspicious cases and sending collected material to specialized labs with expertise in Plague testing and to the State Health Department are mandatory procedures.[2]

Laboratory Findings

Following a thorough history and physical exam, patients suspected to be infected by the plague, such as a patient presenting with fever living in an endemic region, require a confirmation of the initial diagnosis. Plague is a quarantinable disease covered under international regulations.[3] Patients with bubonic plague suspected to have secondary pneumonic plague should be placed in respiratory isolation until after 48 hours of effective antibiotic administration.[1] In the United States, reporting of suspicious cases and sending collected material to specialized labs with expertise in Plague testing and to the State Health Department are mandatory procedures.[2]


According to the "2014 Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue and Soft Tissue Infections", The diagnosis of bubonic plague is confirmed only by gram stain and culture of aspirated material from suppurative lymph nodes.[1]


Other suggested confirmatory tests that have been frequently used include the following[2]:

  • A 4x increase in Y. pestis antibody titer between acute and convalescent phase serum samples
  • Lysis of Y. pestis by unique bacteriophage in culture


Common laboratory findings may not always be present. They include the following:

Blood Work-Up

Urine Work-Up

Peripheral Smear
  • Rod-shaped bacteria on Giemsa stain and "safety pin" (or bipolar) appearance on Wayson stain
  • Toxic granulations and Dohle bodies
Gram Stain
Culture of Fluids
  • Positive for Y. pestis
Cerebrospinal Fluid Analysis

Collection of Samples

Collection of blood specimens, lymph node aspirates from buboes, sputum samples, and tracheal swabs are needed before the administration of antibiotics. Additionally, cerebrospinal fluid (CSF) collection is required in cases suspected to have meningeal complications of plague.[2]

Blood Samples

Blood should be sent for analysis, culture, and peripheral smear.

  • If clinically stable, at least 3 samples for culture within 45 minutes should be collected before antibiotic administration.
  • Serological diagnosis using passive hemagglutination test (PHA) using Y. pestis F1 antigen. If samples are retrieved within 3-4 weeks of symptoms onset, serological confirmation is highly sensitive.

The use of rapid detection tests, such as ELISA and PCR assays to detect F1 antigen are not routinely used yet. However, they may be helpful to confirm cases of suspected plague when gold standard confirmatory tests are not available.[4][5][2]

Lymph Node Aspiration

Bubo aspiration, using a small sterile syringe containing 1 mL sterile saline, is performed by insertion of the needle into the central part of the bubo. If original aspiration fails, injection of the sterile saline inside the syringe may be performed and then aspirated. The aspirate is then used as follows[2]

  • 2 slide preparations for routine staining, using Giemsa (or Wayson) method and for gram stain
  • 2 slide preparations for direct fluorescent antibody (FA) testing

Aspirate should also be used for culture using sheep blood agar, brain-heart infusion (BHI) broth, and MacConkey agar.

Other Specimens

All aspirates and specimens from CSF, tracheal swab, and sputum also need to be tested using gram stain, Giemsa stain, and FA testing.[2]

Gallery


References

  1. 1.0 1.1 1.2 Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL; et al. (2014). "Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of america.". Clin Infect Dis. 59 (2): e10–52. PMID 24947530. doi:10.1093/cid/ciu296. 
  2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Dennis, David (2009). Plague (PDF). Springer Science+Business Media. p. 597. ISBN DOI 10.1007/978-0-387-09843-2 28. Retrieved Jul 25 2014. 
  3. files/WHA58-REC1/english/Resolutions.pdf "Plague" (PDF). World Health Assembly. WHA. 2005. Retrieved Jul 25 2014. 
  4. Williams JE, Arntzen L, Tyndal GL, Isaäcson M (1986). "Application of enzyme immunoassays for the confirmation of clinically suspect plague in Namibia, 1982.". Bull World Health Organ. 64 (5): 745–52. PMC 2490949Freely accessible. PMID 3492308. 
  5. "International meeting on preventing and controlling plague: the old calamity still has a future.". Wkly Epidemiol Rec. 81 (28): 278–84. 2006. PMID 16841399. 
  6. 6.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.09 6.10 6.11 6.12 6.13 6.14 6.15 6.16 6.17 6.18 6.19 6.20 6.21 6.22 "Public Health Image Library (PHIL), Centers for Disease Control and Prevention". 



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