Overview of Chemical and Biological Weapons/Terrorism Tucker Greene, MD, FAAEM, ACMT Cape Coral, FL.

Overview of Chemical and Overview of Chemical and Biological Weapons/TerrorismBiological Weapons/Terrorism

Tucker Greene, MD, FAAEM, ACMTTucker Greene, MD, FAAEM, ACMT

Cape Coral, FLCape Coral, FL

IntroductionIntroduction

Long History of humans using both agentsLong History of humans using both agents PrecedentsPrecedents

– AncientAncient» Middle Ages - Anthrax contaminated livestockMiddle Ages - Anthrax contaminated livestock

– RecentRecent» Southeast Asia – TricothecenesSoutheast Asia – Tricothecenes

» Iran/Iraq – SarinIran/Iraq – Sarin

» Arum Shryinko – Tokyo subway attackArum Shryinko – Tokyo subway attack


Agent ProgressionAgent Progression– ChemicalChemical

» Industrial process Industrial process

– BiologicalBiological» Agents, offspringAgents, offspring

» toxinstoxins

Different Results than predicted for bothDifferent Results than predicted for both


Persistent v. Non-Persistent Biological:Persistent v. Non-Persistent Biological:– Persistent: AnthraxPersistent: Anthrax– Non-Persistent: VirusesNon-Persistent: Viruses

Persistent v. Non-PersistentPersistent v. Non-Persistent– Persistent: Mustard, VXPersistent: Mustard, VX– Non Persistent: Phosgene, CNNon Persistent: Phosgene, CN


Stability or InfectivityStability or Infectivity– Anthrax Spores: stable, reasonably infective, Anthrax Spores: stable, reasonably infective,

lethal?lethal?– Tularemia, Q-Fever, Brucellosis: unstable, very Tularemia, Q-Fever, Brucellosis: unstable, very

infective, non-lethalinfective, non-lethal


Biological AgentsBiological Agents– Mimic other natural diseasesMimic other natural diseases– Usually incapacitatingUsually incapacitating

Chemical AgentsChemical Agents– Exaggerate or Isolate a particular clinical Exaggerate or Isolate a particular clinical

feature of chemical agents in generalfeature of chemical agents in general– I.e organophosphates and nerve agentsI.e organophosphates and nerve agents

KEY: Mechanism of IntoxicationKEY: Mechanism of Intoxication– Dermal, Inhalation, IngestionDermal, Inhalation, Ingestion

(brief) History(brief) History

DefinitionsDefinitions– Kill: Soman, VXKill: Soman, VX– Injure: PhosgeneInjure: Phosgene– Incapacitate: CS, BZIncapacitate: CS, BZ

CountermeasuresCountermeasures– Until WWI, US not concerned or interestedUntil WWI, US not concerned or interested


Pre-WWI DevelopmentsPre-WWI Developments Ancient: hellebore, mandrake in water Ancient: hellebore, mandrake in water

1000-200 b.c1000-200 b.c Recent:Recent:

– 1700-1850: Chlorine, Mustard 1700-1850: Chlorine, Mustard (dichloroehtylsulfide), chloropicrin(dichloroehtylsulfide), chloropicrin

– Civil War: Dougherty: Chlorine, 3 qts in shellCivil War: Dougherty: Chlorine, 3 qts in shell


Biological:Biological:– Mongols in Caffa 1346, bubonic plague bodiesMongols in Caffa 1346, bubonic plague bodies– Spanish v French 1495, Leprosy Blood in Spanish v French 1495, Leprosy Blood in

Naples against FrenchNaples against French

Protection, ControlProtection, Control

US Civil War: agreed but not adhered toUS Civil War: agreed but not adhered to Hoffman Respirator in 1866Hoffman Respirator in 1866 Archduke Francis murder in 1914, control Archduke Francis murder in 1914, control

among WWI participantsamong WWI participants

Protection, ControlProtection, Control

WWI ChemicalWWI Chemical– German Wilhelm: Gas cloud due to lack of German Wilhelm: Gas cloud due to lack of

shellsshells– Allies: Chlorine responseAllies: Chlorine response

Biological:Biological:– Both sides attempting to use anthrax and Both sides attempting to use anthrax and

glandersglanders

US Chemical Warfare Service US Chemical Warfare Service (CWS) and New Age(CWS) and New Age

Chemical Agents placed in Artillery ShellsChemical Agents placed in Artillery Shells– Cl2, Choropicrin, Mustard, PhosgeneCl2, Choropicrin, Mustard, Phosgene

Biological AgentsBiological Agents– RicinRicin– BrucellosisBrucellosis


Detection, Alarms, TreatmentDetection, Alarms, Treatment– Human and AnimalHuman and Animal– TreatmentTreatment

» InhalationInhalation VomitingVomiting VenesectionVenesection KIKI Steam TentsSteam Tents

» Skin: ZnO, Starch, Boric Acid, CalamineSkin: ZnO, Starch, Boric Acid, Calamine


Biologicals get new start in late 1930s after Biologicals get new start in late 1930s after skepticismskepticism

Nuclear Age comes and biologicals take a Nuclear Age comes and biologicals take a back seat (where someone was sitting)back seat (where someone was sitting)

Chemical Warfare takes second PriorityChemical Warfare takes second Priority– Edgewood (Aberdeen), MDEdgewood (Aberdeen), MD– McClellan, ALMcClellan, AL– Rocky Mountain, CORocky Mountain, CO


Near ending of CWS:Near ending of CWS:– Binary weaponsBinary weapons– Disposal at SeaDisposal at Sea– Disseminated Danger of Disseminated Danger of lesser nations?lesser nations?– Johnston Atoll Destruction programJohnston Atoll Destruction program


Gulf WarGulf War– Iraq with known biological and chemical Iraq with known biological and chemical

weaponsweapons– MARK I KitMARK I Kit

» 2-PAM, atropine, valium2-PAM, atropine, valium

– Pryidostigmine BromidePryidostigmine Bromide– Kamisiyah arsenal detonationKamisiyah arsenal detonation

» MustardMustard» sarinsarin


Aum Shinrikyo CultAum Shinrikyo Cult– Experiments with botulinum and anthrax in Experiments with botulinum and anthrax in

subways yields no impactsubways yields no impact– Later sarin attack kills 50 but injures 5000Later sarin attack kills 50 but injures 5000

DEFENSE (WWI)DEFENSE (WWI)

Mask against Chemical AgentsMask against Chemical Agents Plume identificationPlume identification Mobile DecontaminationMobile Decontamination

– 5% of Division strength5% of Division strength Psychological aspect of persistence: Psychological aspect of persistence:

mustard (low volatility, low dose effect, still mustard (low volatility, low dose effect, still used)used)– ““Gas Mania”Gas Mania”

DEFENSE (WWI)DEFENSE (WWI)

MustardMustard– ConjunctivitisConjunctivitis– Skin burnsSkin burns– Inhalation (worse than phosgene and chlorine)Inhalation (worse than phosgene and chlorine)– Accounted for up to 30% of casualties but 1500 Accounted for up to 30% of casualties but 1500

deaths/52,900 US AEF Force deathsdeaths/52,900 US AEF Force deaths

DEFENSE (WWII)DEFENSE (WWII)

Germans thought US possessed secret gases Germans thought US possessed secret gases beyond GA< GB< GD and feared reprisalbeyond GA< GB< GD and feared reprisal

Continued VigilanceContinued Vigilance– Walt Disney exampleWalt Disney example

Chemical Warfare and the Chemical Warfare and the HealthCare ProviderHealthCare Provider

National Warfare CapabilityNational Warfare Capability

Chemical Warfare AgentsChemical Warfare Agents

Nerve AgentsNerve Agents

OrganophoshatesOrganophoshates

HistoryHistory– Ethanol + Phosphoric AcidEthanol + Phosphoric Acid– Tabun - GATabun - GA– Sarin - GBSarin - GB– Soman- GDSoman- GD– VXVX

OrganophosphatesOrganophosphates

ExamplesExamples


AbsorptionAbsorption– inhalationinhalation– dermaldermal– oraloral

ActivationActivation– ie parathionie parathion

MetabolismMetabolism– cholinesterasecholinesterase

Mechanism of ToxicityMechanism of Toxicity


OrganophosphatesOrganophosphates Clinical EffectsClinical Effects

Clinical EffectsClinical Effects–MuscarinicMuscarinic (postganglionic (postganglionic

parasympathetic)parasympathetic)» ““SLUDGE”SLUDGE”»miosis, bronchorrhea, bradycardiamiosis, bronchorrhea, bradycardia

–Nicotinic (neuromuscular junction)Nicotinic (neuromuscular junction)–Nicotinic (autonomic ganglionNicotinic (autonomic ganglion))



Management/TreatmentManagement/Treatment– DecontaminationDecontamination– StabilizationStabilization– AntidotesAntidotes»AtropineAtropine»PralidoximePralidoxime

Pralidoxime


Delayed ToxicityDelayed Toxicity

– Intermediate SyndromeIntermediate Syndrome

–Peripheral NeuropathyPeripheral Neuropathy»Tri -o-cresyl phosphate (TOCP)Tri -o-cresyl phosphate (TOCP)»Tri -o-cresyl {tolyl} phosphate TOTPTri -o-cresyl {tolyl} phosphate TOTP»Neurotoxic EsteraseNeurotoxic Esterase


Delayed ToxicityDelayed Toxicity

– Intermediate SyndromeIntermediate Syndrome

–Peripheral NeuropathyPeripheral Neuropathy»Tri -o-cresyl phosphate (TOCP)Tri -o-cresyl phosphate (TOCP)»Tri -o-cresyl {tolyl} phosphate TOTPTri -o-cresyl {tolyl} phosphate TOTP»Neurotoxic EsteraseNeurotoxic Esterase


LaboratoryLaboratory–Don’t Need To Treat!!!Don’t Need To Treat!!!

–Cholinesterase LevelsCholinesterase Levels»RBC v PlasmaRBC v Plasma»Variation from BaselineVariation from Baseline

PretreatmentPretreatment

Pyridostigmine (carbamate)Pyridostigmine (carbamate) Used in Gulf WarUsed in Gulf War

VesicantsVesicants

Sulfur Mustard

Phosgene

Lewisite

Inhalational AgentsInhalational Agents


Upper AirwayUpper Airway– Water solubleWater soluble

Middle AirwayMiddle Airway AlveolarAlveolar

– Non-soluble in waterNon-soluble in water Cellular AsphyxiantsCellular Asphyxiants



Cyanide TreatmentCyanide Treatment– NitritesNitrites– ThiosulfateThiosulfate– HydroxycobalaminHydroxycobalamin– Hyperbaric O2Hyperbaric O2

Incapacitating AgentsIncapacitating Agents

Incapacitating AgentsIncapacitating Agents

AnticholinergicsAnticholinergics LSD, other IndolesLSD, other Indoles OpiatesOpiates

Riot Control AgentsRiot Control Agents

Rapid Onset, Upper Airway and GI Rapid Onset, Upper Airway and GI SymptomsSymptoms

CS (o-Chlorobenzylidene)CS (o-Chlorobenzylidene) CN (1-Chloroacetophenone)CN (1-Chloroacetophenone) OtherOther

– DM (Diphenylaminearsine)DM (Diphenylaminearsine)– CR (Dibenzo(b,f)-1:4oxazepineCR (Dibenzo(b,f)-1:4oxazepine– CA (Bromobenzylcyanide)CA (Bromobenzylcyanide)


CSCS– Solid, low VpSolid, low Vp

– ““Tear Gas”Tear Gas”

– Airway irritationAirway irritation

– Conjunctival tearingConjunctival tearing

– Dermal effects can Dermal effects can cause blisteringcause blistering

– IV/Oral can liberate IV/Oral can liberate cyanide moeitiescyanide moeities

CNCN– Solid powderSolid powder

– Same symptoms as CSSame symptoms as CS

– Highly sensitizing to Highly sensitizing to skin with deaths skin with deaths reported with large reported with large exposuresexposures


TreatmentTreatment– Alkaline decon of skin; no hypochloriteAlkaline decon of skin; no hypochlorite– Topical steroids for skinTopical steroids for skin– Local anesthetics for eyesLocal anesthetics for eyes

Field Management of Chemical Field Management of Chemical CasualtiesCasualties

Hot ZonesHot Zones Clean v Decontamination areasClean v Decontamination areas Counter-current or Reverse Airflow for Counter-current or Reverse Airflow for

Decontamination AreasDecontamination Areas TriageTriage

– Potential IDPotential ID– Look for Combined Agents/InjuriesLook for Combined Agents/Injuries– Difficult to Treat CombinationsDifficult to Treat Combinations

DecontaminationDecontamination

ChemicalChemical– Desirable Traits for Desirable Traits for

Dermal DeconDermal Decon

– Physical RemovalPhysical Removal

– AqueousAqueous

– AdsorbentAdsorbent

BiologicalBiological– Dermal not as Dermal not as

Important (T-2 is Important (T-2 is exception)exception)

– HypochloriteHypochlorite

– Environmental UVEnvironmental UV

BIOLOGICALSBIOLOGICALS

HistoryHistory

Secret US Weapons ProgramSecret US Weapons Program Response to Japan during WWIIResponse to Japan during WWII

– Stockpiling 400 kg anthrax bombsStockpiling 400 kg anthrax bombs ExperimentsExperiments

– San Francisco (Serratia marcenscens)San Francisco (Serratia marcenscens)– New York Subway (B. subtilis)New York Subway (B. subtilis)– African Americans exposed to Aspergillus f.African Americans exposed to Aspergillus f.

Use of Biological WeaponsUse of Biological Weapons

RequirementsRequirements– Ease of ProductionEase of Production

– Lethality/IncapacitationLethality/Incapacitation

– Particle sizeParticle size

– Ease of DispersionEase of Dispersion

– StabilityStability

Methods of DeliveryMethods of Delivery– FoodFood

– WaterWater

– AirAir

Use of Biological WeaponsUse of Biological Weapons

Advantage/DisadvantageAdvantage/Disadvantage– Predominantly concerns Predominantly concerns

of the pathogen occurring of the pathogen occurring in aggressorsin aggressors

– PersistencePersistence

– Insidious, low cost, Insidious, low cost, minimal detectionminimal detection

Tactical ConcernsTactical Concerns– Hard to Trace or Hard to Trace or

FingerprintFingerprint

– Terrorism as we now Terrorism as we now have known the have known the anthrax casesanthrax cases

Biological AgentsBiological Agents

AnthraxAnthrax PlaguePlague TularemiaTularemia BrucellosisBrucellosis Q FeverQ Fever

SmallpoxSmallpox Viral EncephalitidesViral Encephalitides Viral Hemorrhagic Viral Hemorrhagic

FeversFevers ToxinsToxins

– PlantsPlants

– AnimalsAnimals

– MycotoxinsMycotoxins

AnthraxAnthrax

HistoryHistory– Bacillus anthracisBacillus anthracis

– Zoonotic:goats sheep, Zoonotic:goats sheep, cattle, swine, horsescattle, swine, horses

– 55thth and 6 and 6thth plagues of plagues of ExodusExodus

– Isolated 1876: KochIsolated 1876: Koch

– Vaccine 1881: Pasteur Vaccine 1881: Pasteur

OrganismOrganism– 1-5 mic x 5-10 mic1-5 mic x 5-10 mic

– Capsule forms in Capsule forms in presence of CO2, presence of CO2, HCO3HCO3

– Sporulation occurs in Sporulation occurs in dead tissue exposed to dead tissue exposed to oxygenoxygen

AnthraxAnthrax

EpidemiologyEpidemiology– 1958: 20-100,000 1958: 20-100,000

cases worldwidecases worldwide

– Since 1970 one Since 1970 one case/decadecase/decade

– Woolsorter’s DiseaseWoolsorter’s Disease

PathogenesisPathogenesis– Antiphagocytic Antiphagocytic

CapsuleCapsule

– Lethal ToxinLethal Toxin

– Edema ToxinEdema Toxin

– Mechanism by cell Mechanism by cell binding and then active binding and then active toxintoxin

AnthraxAnthrax

Clinical DiseaseClinical Disease– CutaneousCutaneous

– InhalationalInhalational

– GastointestinalGastointestinal

– MeningealMeningeal

DiagnosisDiagnosis– CLINICAL CLINICAL

SUSPICION OF SUSPICION OF EXPOSUREEXPOSURE

AnthraxAnthrax

TreatmentTreatment– Pen GPen G

– DoxycyclineDoxycycline

– CiprofloxacinCiprofloxacin

– Many other possibly Many other possibly effectiveeffective

Recombinants may Recombinants may possess resistance as possess resistance as the native vegetative the native vegetative state has lactamasesstate has lactamases

PlaguePlague

HistoryHistory– Pandemics of the 6Pandemics of the 6thth, ,

1414thth, 20, 20thth century century

– 24 Million died from 24 Million died from 1346-13521346-1352

– Endemic throughout Endemic throughout historyhistory

– ZoonoticZoonotic» EnzoonticEnzoontic

» EpizooticEpizootic

Infectious AgentInfectious Agent– Yersinia pestisYersinia pestis

– Gram-neg, non-Gram-neg, non-sporulating, sporulating, coccobacilluscoccobacillus

– pH 6 antigen induced pH 6 antigen induced at low pH for virulenceat low pH for virulence

– Antiphagocytic capsuleAntiphagocytic capsule

– Complex interspecies Complex interspecies toxinstoxins

PlaguePlague

EpidemiologyEpidemiology– Oriental rat flea most Oriental rat flea most

common vectorcommon vector

– Multiple animals serve Multiple animals serve as vectorsas vectors

– US rat squirrel fleasUS rat squirrel fleas

– Endemic in Western Endemic in Western USUS

PathogenesisPathogenesis– 1-10 organism can 1-10 organism can

infect via bitesinfect via bites

– Multiple Virulence Multiple Virulence factorsfactors

– Spread via lymphSpread via lymph

– Sepsis occurs when Sepsis occurs when untreated to all organsuntreated to all organs

PlaguePlague

Clinical FeaturesClinical Features– 80% as bubonic form80% as bubonic form

– 10% as sepsis10% as sepsis

– 10% as pulmonary10% as pulmonary

– As warfare agent As warfare agent presentation would be presentation would be bubonic and bubonic and pulmonarypulmonary

Generally present as Generally present as gram negative gram negative infection with plague infection with plague specific featuresspecific features

PlaguePlague

DiagnosisDiagnosis– DifferentialDifferential

» Cat ScratchCat Scratch

» TularemiaTularemia

» LGVLGV

» ChancroidChancroid

» TBTB

» StreptococccalStreptococccal

» RickettsiaeRickettsiae

Lab ConfirmLab Confirm– Aspiration of BuboAspiration of Bubo

– Wright-Giemsa, Gram Wright-Giemsa, Gram StainStain

PlaguePlague

TreatmentTreatment– Isolation for first 48 hrs of treatmentIsolation for first 48 hrs of treatment– Streptomycin, ceftriaxone, chloramphenical,Streptomycin, ceftriaxone, chloramphenical,– Doxycyclcine all acceptableDoxycyclcine all acceptable– If treated early, buboes do not require drainageIf treated early, buboes do not require drainage– Postexposure Prophylaxis: DoxycyclinePostexposure Prophylaxis: Doxycycline– Immunization: high risk individualsImmunization: high risk individuals

TularemiaTularemia

HistoryHistory– Discovered in 1911 in Discovered in 1911 in

Tulare County, Tulare County, California by McCoyCalifornia by McCoy

– Edward Francis Edward Francis discovered deer fly discovered deer fly transmissiontransmission

– High infectivity after High infectivity after aerosolizationaerosolization

AgentAgent– Francisella tularensisFrancisella tularensis

– Obligate aerobe, Obligate aerobe, coccobacilluscoccobacillus

– Two biovars: US Two biovars: US isolate highly virulent isolate highly virulent for rabbits, humansfor rabbits, humans

TularemiaTularemia

EpidemiologyEpidemiology– Principle reservoir is Principle reservoir is

the tick in the USthe tick in the US

– Abdominal Pain, Abdominal Pain, Pharyngitis, from Pharyngitis, from contaminated water in contaminated water in areas where water areas where water mammals live (non-mammals live (non-US)US)

PathogenesisPathogenesis– Possibly capsularPossibly capsular

– Unclear, no toxinsUnclear, no toxins

– Spreads through skin, Spreads through skin, mucous membranes, mucous membranes, GIGI

– 5-10 organisms5-10 organisms

– Humoral response by Humoral response by MHC II mediated T-MHC II mediated T-cell immunitycell immunity

TularemiaTularemia

Clinical FeaturesClinical Features– Incubation 3-6 dayIncubation 3-6 day

– Ulceroglandular 75%Ulceroglandular 75%» Skin or mucous Skin or mucous

membranes, nodes membranes, nodes >1cm>1cm

– Typhoidal 25%Typhoidal 25%» Smaller nodesSmaller nodes

» Non-mucous Non-mucous membranesmembranes

Multiple Const/Syst Multiple Const/Syst complaintscomplaints– FeverFever

– HAHA

– ChillsChills

– Abdominal painAbdominal pain

– Fluctuant Lymph Fluctuant Lymph nodes (drainage)nodes (drainage)

TularemiaTularemia

DiagnosisDiagnosis– Difficult serology and Difficult serology and

growth medium growth medium proceduresprocedures

– ELISA most reliableELISA most reliable

TreatmentTreatment– StreptomycinStreptomycin

– AminoglycosidesAminoglycosides

– ChloramphenicolChloramphenicol

– TetracyclinesTetracyclines

ProphylaxisProphylaxis– DoxycyclineDoxycycline

BrucellosisBrucellosis

HistoryHistory– Zoonotic infectionZoonotic infection

» DomesticDomestic» WildWild

– Animal Products, contact Animal Products, contact with infected animals, with infected animals, aerosolsaerosols

– Relapsing Fever, associated Relapsing Fever, associated with ruminant abortionwith ruminant abortion

– US actively developed US actively developed warfare agent with Brucellawarfare agent with Brucella

AgentAgent– Non-toxic, Non-toxic,

nonsporulating,aerobic, nonsporulating,aerobic, Gram-neg, coccobacilliGram-neg, coccobacilli

– 6 species with several 6 species with several biovarsbiovars

– Unusual LPS Unusual LPS component of cell component of cell membranemembrane


EpidemiologyEpidemiology– Transmission at Transmission at

abortion, slaughter, and abortion, slaughter, and milkmilk

– Highly infectious in Highly infectious in lab workers who work lab workers who work with the Brucellawith the Brucella

– Fewer than 200 fatal Fewer than 200 fatal cases/yr in UScases/yr in US

PathogenesisPathogenesis– Enter thru skin, GI, Enter thru skin, GI,

mucous membranesmucous membranes

– Phagocytized by WBC Phagocytized by WBC but carried to lymph but carried to lymph nodesnodes

– Placenta may carry Placenta may carry 10101010 bacteria/gram bacteria/gram


Clinical FeaturesClinical Features– diverse, diverse,

variabilityvariability

– 3d to weeks incubation3d to weeks incubation

– Neuropsychiatric along Neuropsychiatric along with fever, cough, with fever, cough, arthritisarthritis

– Mild lab abnormalitiesMild lab abnormalities

DiagnosisDiagnosis– Serum agglutinationSerum agglutination

– PCRPCR

– IgGIgG


TreatmentTreatment– DoxycyclineDoxycycline– StreptomycinStreptomycin– AminoglycosidesAminoglycosides

Prophylaxis Prophylaxis – Prevention (no-vaccine)Prevention (no-vaccine)– DoxycyclineDoxycycline

Q FeverQ Fever

HistoryHistory– 1937 discovery1937 discovery– ZoonoticZoonotic– Coxiella BurnetiiCoxiella Burnetii– 50 g of dried powder 50 g of dried powder

equal to casualty rate of equal to casualty rate of anthrax or tularemiaanthrax or tularemia

– Multiple wars with Multiple wars with soldiers infected from soldiers infected from living in barns, near living in barns, near livestocklivestock

AgentAgent– Close relative of Close relative of

Legionella, not true Legionella, not true rickettsiaerickettsiae

– Obligate intracellular Obligate intracellular pathogenpathogen

– Spore-like formationSpore-like formation

– Phase I/IIPhase I/II

Q FeverQ Fever

EpidemiologyEpidemiology– Extremely infectiousExtremely infectious– Single organism capable of Single organism capable of

diseasedisease– Multiple hosts, arthropod to Multiple hosts, arthropod to

humanhuman– Human infection from Human infection from

livestock same as livestock same as Brucellosis but also shed in Brucellosis but also shed in urineurine

– Urine persistence can infect Urine persistence can infect from objects such as strawfrom objects such as straw

PathogenesisPathogenesis– Inhalation of aerosolsInhalation of aerosols

– Phagocytosis with Phagocytosis with eventual lysis and eventual lysis and releaserelease

Q FeverQ Fever

Clinical FeaturesClinical Features– Incubation 10-40 daysIncubation 10-40 days

– Asymptomatic Asymptomatic seroconversionseroconversion

– Acute Disease:Acute Disease:» Chill,rigors,retroorbital Chill,rigors,retroorbital

HAHA

» Fever, myalgiasFever, myalgias

– Chronic: endocarditisChronic: endocarditis

DiagnosisDiagnosis– SerologicalSerological

» Comp FixationComp Fixation

» Indir Flour AbIndir Flour Ab

» ELISAELISA

Q FeverQ Fever

TreatmentTreatment– TetracyclinesTetracyclines– MacrolidesMacrolides– Quinolones in chronic diseaseQuinolones in chronic disease

ProphylaxisProphylaxis– VaccineVaccine– DoxycyclineDoxycycline

SmallpoxSmallpox

Variola – ds-DNA, Orthopox VirusVariola – ds-DNA, Orthopox Virus– Major: 30% mortality, Asia, AfricaMajor: 30% mortality, Asia, Africa– Minor: 1% mortality, Europe, South AmericaMinor: 1% mortality, Europe, South America

Possible to recover Smallpox from Possible to recover Smallpox from preserved cadavers or recombinant with preserved cadavers or recombinant with monkeypoxmonkeypox

SmallpoxSmallpox

Pathogenesis and Clinical FeaturesPathogenesis and Clinical Features– Highly stable and infective for long periods outside Highly stable and infective for long periods outside

of hostof host– Fever, followed by rash 3-6 days laterFever, followed by rash 3-6 days later– Rash period is infective, lymphoid disseminationRash period is infective, lymphoid dissemination

» Head to toe spreadHead to toe spread

– Incubation avg = 12 daysIncubation avg = 12 days– Sx: fever, delerium, backache, cough (aerosol)Sx: fever, delerium, backache, cough (aerosol)– Hemorrhagic and Flat-type higher mortalityHemorrhagic and Flat-type higher mortality

SmallpoxSmallpox

Diagnosis and TreatmentDiagnosis and Treatment– Dx: Guarnieri bodies = viral aggregationDx: Guarnieri bodies = viral aggregation– Distinguish subclinical Smallpox from VaricellaDistinguish subclinical Smallpox from Varicella– Quarantine for 3 days for rash development post Quarantine for 3 days for rash development post

exposureexposure– VaccinesVaccines

» VacciniaVaccinia

» VIG within 7 days of disease; care if recently VIG within 7 days of disease; care if recently vaccinatedvaccinated

Viral EncephalitidesViral Encephalitides

Viral EncephalitidesViral Encephalitides

Zoonotic virusesZoonotic viruses Aerosolization transmission as well as Aerosolization transmission as well as

insect; route of biological warfare agent a insect; route of biological warfare agent a source of concernsource of concern

Each VE has distinct but similar Each VE has distinct but similar incubation, symptoms and mortalityincubation, symptoms and mortality

Vaccines key to management of VEE, Vaccines key to management of VEE, WEE, EEEWEE, EEE

Viral Hemorrhagic FeversViral Hemorrhagic Fevers

ToxinsToxins

pg607

ToxinsToxins

General Discussion and OverviewGeneral Discussion and Overview– Mechanism of ToxicityMechanism of Toxicity– Diagnosis/RecognitionDiagnosis/Recognition– Treatments/AntidotesTreatments/Antidotes

Overview of Chemical and Biological Weapons/Terrorism Tucker Greene, MD, FAAEM, ACMT Cape Coral, FL.

Documents

french slide

fl slide

ingestion slide

cn slide

glanders slide

calamine slide

shell slide

nonlethal slide