Characteristics and Management of Selected Bioterrorism Agents
Evolving skin lesion 20% if untreated,
Gram stain and culture of Ciprofloxacin;
possibly up to 60 (face, neck, arms), progresses
blood, pleural fluid, CSF, doxycycline.
one 6 injections and
vomiting, abdominal pain, bloody if untreated but data
Abrupt onset of
"flu-like" symptoms, fever, chills, distress develops,
headache, dyspnea, chest pain, Begin treatment
followed in 2 to 5 days by severe when inhalational
hemorrhagic meningitis, sepsis, wait for shock
infections indicate that early treatment significantly decreases the mortality rate.
Nonspecific "flu-like" symptoms, Less than 5% even Blood and bone marrow
None. Only animal Doxycycline plus
incapacitate rather Confirmatory culture and Alternative therapies:
health laboratory network. plus
3-5 days (range Sudden onset of acute febrile
Largely clinical diagnosis. Streptomycin;
Culture of blood, sputum, alternative is
discomfort, cough, and dyspnea appropriately
treated within 18-24 Confirmatory serological ciprofloxacin, and
symptoms progress to cyanosis, hours of symptoms. and bacteriological tests chloramphenicol.
when diagnosis of health laboratory network. Chloramphenicol is
2-14 days (may Nonspecific febrile disease,
uncommon even if Confirmatory testing via
prostration, headache, vomiting, unvaccinated
effective in vitro,
and derived from calf
definitive testing through in experimental
multiforme with bullae, or allergic contact dermatitis.
deficits may be higher after biological attack.
Confirmatory serological tests and viral isolation available through public health laboratory network.
Variable depending Confirmatory serological Supportive therapy.
health laboratory network. effective for Lassa
Pathogens Office at 404 and Congo-Crimean
(Hanta, Congo-Crimean, Rift Valley);Filoviruses (Ebola, Marburg);Flaviviruses (Yellow Fever, Dengue, tick-borne disease viruses)
Treatment and reporting Supportive care -
Pentavalent toxoid Antitoxin might prevent
(typically 12-36 mouth, ptosis, fatigue. As
from the CDC) should Not available to the
immediately following diagnosis. Anaphylaxis and serum sickness are potential complications from antitoxin.
Aminoglycosides and clindamycin must not be used.
fever, cough, pulmonary edema, available but
symptoms may respiratory failure, circulatory
appear as early collapse, hypoxemia resulting in is likely to be high as 4-8 hours
testing available through decontamination if
Probably low (little Clinical diagnosis.
headache, nonproductive cough. data available for
T-2 mycotoxins: Minutes to hours Abrupt onset of mucocutaneous Severe exposure
Consult with local health Clinical support. Soap No vaccine
specimen collection and within 4-6 hours
procedures. Confirmation toxicity; washing
requires testing of blood, within 1 hour may
tissue and environmental eliminate toxicity
No effective medications or antidotes.
Physicians should report noticeable increases in unusual illnesses, symptom complexes, or disease patterns (even without definitive diagnosis) to public
health authorities. Prompt reporting of unusual patterns of illness can allow public health officials to initiate an epidemiologic investigation earlier than would be
possible if the report awaited definitive etiologic diagnosis. If you suspect an unusual disease or possible outbreak, please call your state or local
. These numbers are available at:
Information contained in this table was current as of November 2, 2001, and is intended for educational purposes only. Medication information should be researched and verified before initiation of patient treatment.
2 Different scenarios may require different treatment regimens. Please consult listed references and an Infectious Disease specialist for definitive dosage
Other agents with in vitro
activity suggested for use in conjunction with ciprofloxacin or doxycycline for treatment of inhalational anthrax include rifampin, vancomycin,
imipenem, chloramphenicol, penicillin and ampicillin, clindamycin, and clarithromycin.
4 This table was compiled from the following references:
Arnon SS, et al. Botulinum toxin as a biological weapon. JAMA
Centers for Disease Control and Prevention. Update: investigation of bioterrorism-related anthrax and interim guidelines for clinical evaluation of persons with possible anthrax. MMWR
Centers for Disease Control and Prevention. Update: investigation of bioterrorism-related anthrax and interim guidelines for exposure management and antimicrobial therapy, October 2001. MMWR
Centers for Disease Control and Prevention. Vaccinia (smallpox) vaccine: recommendations of the Advisory Committee on immunization Practices (ACIP), 2001. MMWR
Chin J, Ed. Control of Communicable Diseases, Manual
. 2000. Washington, DC: American Public Health Association.
Dennis DT, et al. Tularemia as a biological weapon. JAMA
Dixon TC, et al. Anthrax. N Engl J Med
Drugs and vaccines against biological weapons. Med Lett
Henderson DA, et al. Smallpox as a biological weapon. JAMA
Inglesby TV, et al. Anthrax as a biological weapon. JAMA
Inglesby TV, et al. Plague as a biological weapon. JAMA
Klietmann WF, et al. Bioterrorism: implications for the clinical microbiologist. Clin Microbiol Rev
U.S. Army Medical Research Institute of Infectious Diseases. Medical management of biological casualties handbook, 4th edition
. 2001. Available at: http://www.usamriid.army.mil/education/bluebook.html.
CDC - Centers for Disease Control and Prevention
CSF - Cerebrospinal Fluid
IND - Investigational New Drug
PCR - Polymerase Chain Reaction
RBC - Red Blood Cell
SMX - Sulfamethoxazole
TMP - Trimethoprim
USAMRIID - United States Army Medical Research Institute of Infectious Diseases
WBC - White Blood Cell
answer that, I would like to return full circle tothe excellent introduction by Gary Kupfer. I fullyagree that lessons learned in pediatric psycho-oncology can, indeed should, be used by practi-child psychiatry attendings at the Massachusettstioners in any ﬁeld who deal with medically illGeneral Hospital Psychiatric Emergency Room. children. I no longer work exclusively—rarely atThe m
Author: Malte Schütz, MD Quick Reference Guide to Antiretrovirals Regular updates to this publication are posted on the Medscape Web site at http://hiv.medscape.com/updates/quickguide . Please check regularly to ensure you are using the most recent edition. The latest changes are highlighted in blue text. Guide to Antiretroviral Agents Nucleoside Reverse Transcriptase Inhibitor