Crozet Annals of Medicine: All Fall Down


Fall is in the air. The nights are cool, the days are shortening, and in the surest sign of all, the UVA students are back. This is nice; they bring energy and beauty with them. They also bring traffic and parking headaches.

We see the students in the ER disproportionally in the first week back to school. Away from home for the first time, newly liberated from their parents, they tend to wander into new adventures that land them on our doorstep. After that they acclimate and we tend to see little of them until finals when stress and fatigue take their toll in emotional and physical wellness.

But summer is not truly over. We are still seeing the usual excess trauma associated with the warm weather. People are out driving, boating, motorcycling, drinking. In one recent week we had five fatal car crashes.

That was a tough week on us and the EMS/Police communities that are our extended family in the field. There was a palpable pall overlying the otherwise also very busy ER. So seeing the returning healthy students with minor injuries and illnesses is most refreshing. I guess everybody gets refreshed in different ways. ER docs are a different breed.

The students are diverse lot hailing from all points of the compass. Along with their backpacks and laptops they carry back with them the potential for exotic diseases that we rarely see here.  I have treated them for dengue fever and malaria and screened them for chikungunya and MERS, the Middle Eastern respiratory virus, as well as TB and hantavirus.

Now the CDC has asked to be on the alert for another exotic foe that does not naturally occur here; Plague!

Yes, plague, the Black Death, bubonic plague, the scourge of the Middle Ages has infected a dozen Americans this year, killing four.

Fortunately plague does not exist naturally in Virginia, but it is endemic in the western United States where some of our students hail from.
Plague has been recorded in the rest of the world since before biblical times but only came to US shores recently. The first outbreak in the U.S. was in San Francisco in 1900, brought in by rats on a ship from China. From there it slowly spread eastward, as far east as Colorado to date.

Plague is caused by a bacterium called Yersinia pestis. It is quite lethal, with mortality rates upwards of 80 percent in untreated individuals. It is so lethal that during the Middle Ages nearly half of Europe’s population was wiped out and it took centuries for the population to recover to its previous levels.

Plague is spread from person to person in multiple ways. The classic teaching is that fleas spread the disease by biting infected rats and then biting humans. This does happen and is likely how most of the U.S. cases occurred, although in the American West prairie dogs are the most common endemic reservoir of Yersinia pestis.
Plague can also be spread by contact with dead animals that had the plague, person-to-person contact, respiratory droplets, surface contamination, fecal oral transmission and in rare cases can be food-borne. You don’t want this bacterium on a cruise ship.

Eighty percent of patients with plague present with the classic bubonic form of plague. Bubonic plague is named for the buboes that form in infected individuals. Buboes are golf ball-sized swollen lymph nodes, usually in the groin (bubo means groin in Greek) but also in the armpits, neck, and behind the knees.

Death follows in next several days if untreated.

Fortunately we have very effective treatments, and many common antibiotics will kill Yersinia if the disease is recognized early enough

Unfortunately 20 percent of cases of plague present as either septicemic or pneumonic plague. The disease is primarily in the blood or the lungs and the characteristic buboes do not form. This presentation looks very much like the flu or other nonspecific illnesses with fever, headache, cough and malaise.

Unlike the flu, though, pneumonic plague and septicemic plague progress ferociously and rapidly with death coming in hours or days. As the old children’s rhyme goes, “ashes, ashes (achoo, achoo) all fall down,” a fairly accurate description of the progression and contagiousness of the disease. Often the patients’ fingers and toes will turn black with the onset of gangrene and this gruesome finding is responsible for the moniker the Black Death. (ICD 10 code 020.9 if I ever need to bill for it.)

So I shall keep plague in mind for a little while longer. Everything old is new again.
Fortunately fall not only brings colorful foliage and football but also ends the plague season until next spring and summer. Ashes ashes all fall down.


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