However, because plague, unlike smallpox, is spread by large respiratory droplets, close contact is required for transmission Clinical Manifestations Bubonic plague is characterized by the classic bubo, a tender, enlarged, fluctuant lymph node in the distribution of the infected flea bite Fever and malaise are usually present Bubonic plague may progress to septicemia as bacteria gain access to the circulation; 80% of bubonic plague victims have positive blood cultures Petechiae, purpura, and overwhelming disseminated intravascular coagulation (DIC) may develop Pneumonic plague may arise secondarily after blood-borne seeding of the lungs or may be seen primarily after aerosol exposure Symptoms include high fever, chills, malaise, fatigue, headache, and cough Chest radiographs may reveal a patchy or consolidated bronchopneumonia, and the classic clinical finding is one of blood-streaked sputum; DIC and an overwhelming sepsis may develop as the disease progresses Meningitis develops in 6% of cases Untreated pneumonic plague has a mortality rate approaching 100% A presumptive diagnosis of plague can be made by observing the classic bipolar-staining “safety pin”—like rods in Gram or Wayson stains of sputum, aspirated lymph node material, or cerebrospinal fluid Confirmation is obtained via blood, sputum, or aspirate culture Management Droplet precautions should be employed in cases of suspected pneumonic plague Such precautions should be continued in confirmed cases until sputum cultures are negative Standard precautions are adequate in managing bubonic plague victims Given the incubation period, decontamination would not be necessary in a clinical setting See Table 132.3B for detailed treatment recommendations for children Smallpox CLINICAL PEARLS AND PITFALLS