Characteristics and Management of Selected Bioterrorism Agents Disease/ Incubation Clinical Syndrome Lethality Diagnostic Tests Treatment2 Chemoprophylaxis BACTERIAL AGENTS Cutaneous: 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.
doxycycline plus one 6 injections and Gastrointestinal: Nausea,
vomiting, abdominal pain, bloody if untreated but data
inhalational anthrax.3 Inhalational: 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. Disease/ Incubation Clinical Syndrome Lethality Diagnostic Tests Treatment2 Chemoprophylaxis BACTERIAL AGENTS
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 gentamicin;
TMP/SMX plus gentamicin.
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
Disease/ Incubation Clinical Syndrome Lethality Diagnostic Tests Treatment2 Chemoprophylaxis BACTERIAL AGENTS
2-14 days (may Nonspecific febrile disease,
uncommon even if Confirmatory testing via
Disease/ Incubation Clinical Syndrome Lethality Diagnostic Tests Treatment2 Chemoprophylaxis VIRAL AGENTS
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)
Incubation Clinical Syndrome Lethality Diagnostic Tests Treatment2 Chemoprophylaxis BIOLOGICAL TOXINS
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. Incubation Clinical Syndrome Lethality Diagnostic Tests Treatment2 Chemoprophylaxis 1 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 health department. 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 information. 3 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 . 2001;285:1059-1070.
Centers for Disease Control and Prevention. Update: investigation of bioterrorism-related anthrax and interim guidelines for clinical evaluation of persons with possible anthrax. MMWR . 2001;50:941-948.
Centers for Disease Control and Prevention. Update: investigation of bioterrorism-related anthrax and interim guidelines for exposure management and antimicrobial therapy, October 2001. MMWR . 2001;50:909-919.
Centers for Disease Control and Prevention. Vaccinia (smallpox) vaccine: recommendations of the Advisory Committee on immunization Practices (ACIP), 2001. MMWR . 2001;50:RR-10.
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 . 2001;285:2763-2773. Dixon TC, et al. Anthrax. N Engl J Med . 1999;341:815-826. Drugs and vaccines against biological weapons. Med Lett . 2001;43:87-89. Henderson DA, et al. Smallpox as a biological weapon. JAMA . 1999;281:2127-2137. Inglesby TV, et al. Anthrax as a biological weapon. JAMA . 1999;281:1735-1745. Inglesby TV, et al. Plague as a biological weapon. JAMA . 2000;283:2281-2290. Klietmann WF, et al. Bioterrorism: implications for the clinical microbiologist. Clin Microbiol Rev . 2001;14:364-381. 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. Abbreviations: 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