1. Incubation period: 9 days to more than 1 year, usually (in humans) 2 to 12 weeks

2. Initial symptoms are nonspecific

3. Neurologic symptoms after prodromal period, which lasts 2 to 10 days; may be in the form of furious or paralytic (dumb) rabies

4. Furious rabies: increasing agitation, hyperactivity, seizures, and episodes in which the patient may thrash about, bite, and become aggressive, alternating with periods of relative calm

5. Paralytic (dumb) rabies: progressive lethargy, incoordination, ascending paralysis, coma

1. Observe the offending animal.

2. Wash the area thoroughly with soap and water to reduce contamination. Cleanse the wound with either povidone-iodine solution or benzalkonium chloride (Zephiran). If neither of these agents is available, use 70% alcohol (ethanol) solution.

3. Infiltrate the wound edges with local anesthetic (e.g., procaine hydrochloride 1%).

4. Administer rabies immune globulin.

5. Administer human diploid cell vaccine (HDCV). The vaccine is given as a 1-mL dose regardless of the patient’s age on days 0, 3, 7, and 14. Inject it intramuscularly into the deltoid muscle in an adult and into an anterior thigh muscle in an infant or small child. Do not give the vaccine in the same syringe or site as HRIG, and do not give it into the buttock (in order to avoid a poorly immunogenic deposition into fat). The World Health Organization continues to recommend a fifth dose on day 28 for immunocompromised patients.

6. A person who has undergone preexposure immunization with HDCV or purified chick embryo cell vaccine (PCEC) should receive booster doses of the same vaccine on days 0 and 3.

7. After immunization, antirabies titers 2 to 4 weeks after the immunization series is completed should show complete virus neutralization at a 1 : 5 serum dilution in the rapid fluorescent focus inhibition test (RFFIT) or a titer of at least 0.5 international units. If the response is inadequate, an additional booster dose of rabies vaccine can be given each week until a satisfactory response is obtained.

1. Obtain preexposure immunization in humans by administering either HDVC or PCEC in three 1-mL intramuscular (deltoid muscle in adults and anterior thigh muscle in children) injections on days 0, 7, and 21 or 28.

2. Check the antirabies titer, and give a booster dose of vaccine if the titer drops below complete virus neutralization at a 1 : 5 serum dilution in the RFFIT or a titer of at least 0.5 international units.

1. Characteristic feature: regional lymphadenitis, usually involving lymph nodes of the arm or leg

2. Raised, red, slightly tender, and nonpruritic papule with a small central vesicle or eschar that resembles an insect bite at the site of primary inoculation

3. Mild systemic symptoms including fever (usually <39° C [102.2° F]), chills, malaise, anorexia, and nausea

4. Evanescent morbilliform and pleomorphic rashes lasting up to 48 hours

5. Parinaud’s oculoglandular syndrome: conjunctivitis and ipsilateral, enlarged, tender preauricular lymph node

6. Rarely, encephalopathy, seizures, transverse myelitis, arthritis, splenic abscess, optic neuritis, or thrombocytopenic purpura

1. Cat-scratch disease usually resolves spontaneously in weeks to months. In approximately 2% of patients (usually adults) the course is prolonged and involves systemic complications.

2. Antibiotics that may help shorten the course of illness include trimethoprim/sulfamethoxazole, rifampin, gentamicin, and ciprofloxacin (see Appendix H). Limited data at this time suggest that for isolated lymph node involvement, treat with azithromycin (10 mg/kg on day 1 [500 mg maximum], followed by 5 mg/kg/day for 4 days [up to 250 mg/day]) for a 5-day course. For patients intolerant of azithromycin, alternatives include trimethoprim/sulfamethoxazole, rifampin, gentamicin, or ciprofloxacin.

3. The following antibiotics have been studied and found to be ineffective: amoxicillin/clavulanate, erythromycin, dicloxacillin, cephalexin, ceftriaxone, cefaclor, and tetracycline.

1. After incubation period (average 7 to 12 days, range 1 to 26 days), initial phase (4 to 7 days) of abrupt high fever, chills, headache, malaise, prostration, myalgias, lymph node enlargement, nonproductive cough, and prominent conjunctival suffusion without exudate; nausea, vomiting, and abdominal pain possible

2. Apparent recovery for a few days, followed by return of less dramatic fever associated with relentless headache with meningeal signs; severe cases initially interpreted as aseptic meningitis, infectious hepatitis, or fever of unknown origin (FUO)

3. Maculopapular, petechial, or purpuric rash; uveitis (iridocyclitis); arrhythmias; splenic enlargement

4. Weil’s syndrome (icteric form): jaundice, petechial hemorrhages, renal insufficiency

1. The treatment of choice is doxycycline, 100 mg PO q12h for 7 days. Tetracycline, 500 mg PO q6h for 7 to 14 days, is an alternative. Another choice is procaine penicillin G, 3 million units/day IM divided q6h for 7 to 10 days.

2. A Jarisch-Herxheimer reaction may be seen within a few hours of initial treatment.

3. Doxycycline 200 mg PO once weekly may be used to prevent illness when traveling in endemic countries and participating in high-risk activities such as rafting, kayaking, or swimming in fresh water.

1. Streptobacillary rat-bite (Haverhill) fever:

2. Spirillary rat-bite fever:

1. Administer procaine penicillin 600,000 units IM q12h for 7 to 10 days. Alternative drugs for penicillin-allergic persons are tetracycline, 30 mg/kg/day PO divided q6h, or streptomycin, 15 mg/kg/day IM divided q12h.

2. Erythromycin is not effective.

1. Abrupt onset of fever, often with chills and temperature up to 41.5° C (106.7° F)

2. Headache, which may mimic meningitis in severity

3. Hepatomegaly, splenomegaly

4. Six clinical presentations

1. No specific symptoms or signs; thus the nickname “mimic” disease

2. Most characteristic clinical manifestation: undulating fever

3. Acute form: headache, weakness, diaphoresis, myalgias, arthralgias, anorexia, constipation, weight loss, hepatomegaly and splenomegaly

4. Subacute or “undulant” form: similar to acute, but milder symptoms, with addition of arthritis and orchitis

5. Chronic form: symptoms persist for more than 1 year; arthralgias and extra-articular rheumatism, mimics chronic fatigue syndrome

6. Rare but serious complications include endocarditis, neurobrucellosis with meningitis, and hepatic abscess.

1. Administer doxycycline 100 mg PO q12h for 6 weeks plus either streptomycin 1 g IM daily for the first 14 to 21 days, gentamicin 5 mg/kg/day IM for 7 days, or rifampin 600 to 900 mg PO once daily for 6 weeks.

2. In pregnancy treat with rifampin 900 mg PO daily for 6 weeks, with the addition of trimethoprim/sulfamethoxazole in the second trimester.

3. For children younger than 8 years also give oral trimethoprim/sulfamethoxazole and rifampin for 4 to 6 weeks, with gentamicin added for the first 14 days if osteoarticular, neural, or endocarditis manifestations are present. For children older than 8 years, antibiotic choices are the same as for adults.

1. Nausea, vomiting, and abdominal pain approximately 5 days after ingestion of infective meat; diarrhea or fever possible; gastrointestinal symptoms persisting for 4 to 6 weeks

2. Larvae invade skeletal muscle as early 7 days after ingestion.

3. After 2 weeks: cough, dyspnea, pleuritic chest pain, hemoptysis, meningitis symptoms, headache

4. After 3 weeks: myalgias, muscle stiffness

1. No satisfactory, safe, and effective drug is available for the elimination of larvae.

2. Thiabendazole, 25 mg/kg q12h for 5 days (maximum 3 g/day), is effective against adult worms in the intestine, but its efficacy against larvae is questionable. Mebendazole (200 to 400 mg q8h for 3 days, then 400 to 500 mg q8h for 10 days) is better tolerated, but poor intestinal absorption reduces its use in extraintestinal trichinosis. Albendazole and flubendazole are well absorbed and may be more effective, but supporting data are scarce.

3. Use prednisone, 30 to 60 mg/day PO, for 10 to 30 days for relief from severe inflammatory manifestations.

1. Cook meat to an internal temperature of 65.6° C to 77° C (150° F to 170.6° F).

2. Most Trichinella larvae are killed by freezing. Holding the meat at −15° C (5° F) for 20 days, −23.3° C (−9.9° F) for 10 days, or −28.9° C (−20° F) for 6 days is recommended.

3. Salting, drying, and smoking are not always effective. Trichinella nativa found in Arctic mammals is resistant to freezing.

1. Prodrome of fever, myalgia, and variable respiratory symptoms, which may include cough and shortness of breath with minimal bronchospasm, followed by rapid onset of acute respiratory distress

2. Headache, chills, abdominal pain, nausea, vomiting; possible hemorrhage related to thrombocytopenia

3. Rapid deterioration, including respiratory failure and hypotension

1. Eliminate rodents, and reduce the availability of food sources and nesting sites used by rodents inside the home. Maintain snap traps and use rodenticides; in areas where plague occurs, control fleas with insecticides.

2. Keep food and water covered and stored in rodent-proof metal or thick, plastic containers. Keep cooking areas clean.

3. Dispose of clutter. Contain and elevate garbage.

4. Remove food sources that might attract rodents. Avoid feeding or handling rodents.

5. Spray dead rodents, nests, and droppings with a general-purpose household disinfectant or 10% bleach solution before handling. Dispose of all excreta and nesting materials in sealed bags. Always wear rubber or plastic gloves.

6. Avoid contact with rodents and rodent burrows. Do not disturb dens.

7. Do not use cabins or other enclosed shelters that are rodent infested until they have been appropriately cleaned and disinfected. Seal holes and cracks in dwellings to prevent entrance by rodents. Avoid sweeping, vacuuming, or stirring dust until the area is thoroughly wet with disinfectant.

8. Do not pitch tents or place sleeping bags in areas close to rodent feces or burrows or near possible rodent shelters (garbage dumps, woodpiles).

9. If possible, do not sleep on bare ground.

10. Burn or bury all garbage promptly. Clear brush and trash from around homes and outbuildings.

11. Use only bottled water or water that has been disinfected for oral consumption, cooking, washing dishes, and brushing teeth.

Bubonic Plague

Septicemic Plague

Pneumonic Plague

1. Initiate treatment if there is any suspicion that the disease may be present.

2. The drug of choice is streptomycin, 30 mg/kg/day IM divided q6h for 5 days. A less preferred alternative is gentamicin, 5 mg/kg/day IV divided q6h, reduced to 3 mg/kg/day after clinical improvement. Tetracycline is often used concurrently with streptomycin. The loading dose is 15 mg/kg PO up to 1 g total dose. Follow this with 40 to 50 mg/kg divided q4h on the first day. Thereafter, administer 30 mg/kg PO divided q6h for 10 to 14 days. An alternative to tetracycline is chloramphenicol, administered in a loading dose of 25 mg/kg PO up to 3 g total, followed by 50 to 75 mg/kg PO divided q6h for 10 to 14 days. Sulfadiazine is a less satisfactory alternative. A loading dose of 25 mg/kg is given orally, followed by 75 mg/kg orally divided q6h for 10 to 14 days. If none of these drugs is available, give cotrimoxazole (320 mg trimethoprim and 1600 mg sulfamethoxazole) PO q12h for 14 days. Ciprofloxacin (400 mg IV q12h for adults; 15 mg/kg IV q12h for children) is another alternative.

1. The greatest risk for contagion is by aerosol transmission from patients with pneumonic plague. Therefore keep infected patients in strict quarantine for a minimum of 48 hours after antibiotic therapy is begun (suspected case) or 4 days after beginning antibiotic therapy (confirmed case). Contact personnel should wear gloves, gowns, masks, and eye protection.

2. Treat individuals directly exposed to pneumonic plague prophylactically with tetracycline, 500 mg PO q6h for 6 days, for adults, or cotrimoxazole (otitis media dose) for children.

Inhalation Anthrax

Cutaneous Anthrax

Gastrointestinal (Ingestion) Anthrax

1. For cutaneous anthrax: ciprofloxacin 500 mg PO q12h in adults or 10 to 15 mg/kg/day divided q12h (up to adult dose of 500 mg q12h) in children, or doxycycline 100 mg PO q12h in adults or 4.4 mg/kg/day divided q12h (up to adult dose of 100 mg q12h) in children, for 60 days.

2. If systemic symptoms are present, intravenous antibiotic therapy should be initiated. If patients clinically improve, they can be changed to amoxicillin 500 mg PO q8h in adults and 80 mg/kg/day divided q8h in children.

3. For inhalational and gastrointestinal anthrax: treatment begins with ciprofloxacin or doxycycline in addition to two other agents (options include rifampin, chloramphenicol, vancomycin, penicillin, ampicillin, imipenem, clindamycin, and clarithromycin). If the patient’s condition improves, change to an oral regimen of ciprofloxacin or doxycycline for a total course of 60 days.

4. For anthrax during pregnancy: treatment for the various forms is the same; the risk of doxycycline or ciprofloxacin during pregnancy is outweighed by the potential mortality resulting from undertreated anthrax infection.

1. If vaccine is available, all exposed persons should be vaccinated with three doses of anthrax vaccine (days 0, 14, and 28).

2. Begin antibiotic prophylaxis immediately after exposure with ciprofloxacin (500 mg PO q12h) or doxycycline (100 mg PO q12h). If it is determined that the strain of anthrax is penicillin susceptible, therapy can be changed to penicillin or amoxicillin (500 mg PO q8h for adults; 40 mg/kg in three divided doses q8h for children weighing less than 20 kg).

3. Continue antibiotic prophylaxis until three doses of vaccine have been administered. If vaccine is not available, antibiotics should be continued for 60 days (to treat delayed germination of spores in the event of inhalation).

1. Incubation period of 1 to 5 days

2. Pustular cutaneous eruptions

3. Thick indurated lymphatics that may ulcerate

4. Mucopurulent discharge from the eyes or nose

5. Pneumonia

6. Depending on the severity, the patient may have anorexia, fever, weight loss, headache, nausea, diarrhea, or septicemic shock.

1. Administer sulfadiazine, 100 mg/kg/day divided q8h for 3 weeks.

2. Treatment with tetracyclines and streptomycin is also recommended.

1. Sudden onset of high fever, headache, malaise, cough, sore throat, and myalgias

2. Gastrointestinal manifestations such as diarrhea may also occur.

1. Treatment is recommended for patients with confirmed or suspected influenza who require hospitalization; have progressive, severe, complicated illness; and those at risk for severe disease (children <2 years, adults >65 years, pregnant women or those less than 2 weeks post partum, and persons with severe medical conditions). More information can be found at http://www.cdc.gov/flu.

2. Administer oseltamivir (Tamiflu) 75 mg PO q12h (adult dose and adolescents 13 years and older) for 5 days. Treatment should begin within 48 hours of symptom onset. The recommended dose of oseltamivir for pediatric patients older than 1 year is shown in Table 43-1. Oseltamivir capsules may be opened and mixed with sweetened liquids. Oseltamivir is not recommended for pediatric patients younger than 1 year old.

1. The recommended dose of oseltamivir for prophylaxis of influenza in adults and adolescents 13 years and older following close contact with an infected individual is 75 mg once daily for 10 days. The recommended dose for pediatric patients older than 1 year and older is shown in Table 43-2.