Tox in The Land: Biological Warfare Agents

Definition

  • Use of viruses, bacteria, fungi, biological toxins to induce illness, incapacitation or death for warfare purposes

  • More than 180 agents have been researched or employed

    • We will focus on just a few…

  • Aerosolization most likely the method of dissemination

    • Person-to-person, vectors, ingestion or direct contact also may be employed

How to Recognize in the ED

  • Early on difficult, presentations are non-specific

  • Clues of a biological attack include unusually large numbers of patients with similar symptoms

  • Other red flags

    • Those presenting from areas of similar living or work locations

    • Attend the same event

  • Can easily overwhelm health-care systems

- Agents to Know for Boards -

Anthrax

  • Bacillus anthracis

  • Forms/Exposures

    • Cutaneous

    • Ingestion

    • Inhalational – most lethal form

      • As few as 2500 spores to cause infection

      • 4-10 days of flu like symptoms>rapid deterioration>hemorrhagic mediastinitis

      • Mediastinal widening on CXR

  • Treatment

    • Ciprofloxacin and doxycycline (penicillin resistant)

Cutaneous anthrax

Source: https://commons.wikimedia.org/wiki/File:Cutaneous_anthrax.jpg

Hemorrhagic mediastinitis

Source: https://radiopaedia.org/cases/acute-mediastinitis

“The Plague” - Yersinia pestis

  • ~25 million people died in Europe from 1347-1351

    • Mongols brought the plague to Crimea which spread to the rest of Europe

  • Types

    • Septicemic

    • Bubonic

    • Pneumonic

      • 100% fatal if untreated

      • Potential human to human transmission

      • Flea >human

  • Treatment

    • Streptomycin, ciprofloxacin, doxycycline

 
 
 

Smallpox umbilicated rash

Source: https://commons.wikimedia.org/wiki/File:Pustular_eruption_of_smallpox_on_face_Wellcome_L0032957.jpg

Smallpox

  • Variola virus

  • Eradicated in U.S. in 1949, worldwide in 1980 per WHO

  • Types of presentation

    • Ordinary

    • Modified

      • Mild occurs in vaccinated individuals; can look like Varicella

    • Malignant

      • Pustules that results in skin sloughing similar to 3rd degree burns

    • Hemorrhagic

      • Bleeding into skin, mucous membranes and GI tract

  • Overall mortality approx. 30%

  • Treatment

    • Cidofivir theorized as short-term treatment and ppx

    • Vaccination within 3 days will limit symptoms

Umbilicated rash - all lesions in the same stage

Source: https://cdn2.picryl.com/photo/1975/12/31/child-with-smallpox-bangladesh-arm-detail-3a796a-640.jpg

Ricin

  • Naturally occurring protein from castor oil plant

    • Castor bean — Memory tip: castor = beetle

  • Inactivated ribosomal activity>inhibition protein synthesis

  • Median lethal dose 5-10 mcg/kg

  • Presentation

    • Nausea, diarrhea

    • Tachycardia, hypotension

    • Seizures

  • If a castor bean is ingested, the whole bean does not cause toxicity bean is macerated

  • Treatment

    • Supportive care

Source: https://upload.wikimedia.org/wikipedia/commons/3/3d/Castor_beans1.jpg

Source: https://live.staticflickr.com/65535/24134420541_758cee5988_b.jpg

POST BY: DR. RAY JABOLA (R3)

FACULTY EDITING BY: DR. LAUREN PORTER

References

  1. Goldfrank's toxicologic emergencies 11th edition; Lewis R Goldfrank; Robert S Hoffman; Mary Ann Howland; Neal A Lewin; Lewis Nelson; Silas W Smith

  2. Anthrax. Primary Care Dermatology Society: https://www.pcds.org.uk/clinical-guidance/anthrax

  3. Hayoun MA, King KC. Biologic Warfare Agent Toxicity. [Updated 2022 Apr 28]. In: StatPearls[Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441942/

  4. The Plague In England. https://englishhistory.net/stuarts/the-plague-in-england/

ToxLauren McCaffertytox, toxicology, biologic warfare, ricin, anthrax, smallpox, plague