Plague: History and contemporary analysis
Introduction
Plague is primarily a murine zoonosis. Humans are incidental hosts that do not contribute to the natural cycle of the disease outside of epidemics. The Yersinia pestis bacterium is the causative agent of plague and can be transmitted by fleas, bites, scratches, aerosols, or contaminated food.1 Plague is one of the most important diseases shaping the history of humanity because few microbes have killed as many as a third of the whole population during a pandemic or have changed the course of history.1 The transmission of Y. pestis during a pandemic is not completely understood. Y. pestis is primarily transmitted between wild animals by ectoparasites, fleas in particular. Sporadic cases in humans can be the result of various modes of transmission, but it is difficult to explain historical plague pandemics by transmission solely by rat fleas. The mode of plague transmission during pandemics has been the subject of a very heated debate.
It should be noted that the description of the buboes associated with an epidemic provided a clue leading to plague. A precise historical description by Procopus indicated that the Justinian plague was caused by Y. pestis. The second pandemic plague, which started in the 14th century (the “Black Death”), was well described by Guy de Chauliac as an epidemic associated with adenitis (bubo) and high mortality.2 Currently, we do not know of any other epidemic diseases of this nature, and it is clear that this disease was also plague.
Section snippets
History
The analysis of plague corpses in Marseilles was instrumental in developing the field of paleomicrobiology. In these studies, modern diagnostic tools were used to analyze the dental pulp of people thought to have died of plague.3, 4, 5, 6 This analysis allowed the role of Y. pestis to be confirmed and the genotype of the causative agent to be identified.
The origin of the first historical epidemics of plague is unclear, as the name “plague” refers to nonspecific diseases. In contrast, the word
Epidemiology
Overall, the epidemiology of plague must be seen in a much less diagrammatic manner than in the past. However, outbreaks of either bubonic or pneumonic plague, some causing dozens of deaths, have recently been reported in northeastern Democratic Republic of Congo. Many rodents are susceptible to plague, as many other animals are.1, 12 Sporadic cases of this zoonosis in humans can be due to transmission by rodent fleas or to the consumption of infected food, to wounds or to exposure to
Geographical distribution
In recent years, 90% of reported cases of plague occurred Africa, specifically eastern Africa, central Africa and Madagascar, with small outbreaks occurring in North Africa. Currently, only the Orientalis biovar is distributed worldwide and is thus the only pandemic biovar. From 1958 to 2008, 17,000 cases were reported in Madagascar, 9000 in Tanzania, 13,000 in Congo, 4800 in India, 3,500 in Vietnam, 5500 in Myanmar, 3693 in Brazil, 4091 in Peru and 438 in the United States (Fig. 4). Recently,
Routes of transmission
Sporadic cases of human plague are acquired from animals by various routes. Plague, being a zoonosis, can be contracted by contact with animals or their parasites12 and is most often acquired through flea bites, but this disease can also be transmitted by animal scratches or by the inhalation of infected particles from animals having a respiratory infection or during the autopsy of infected animals.1, 21, 22 Plague can also be contracted in laboratories in which Y. pestis is handled.23
Microbiology and pathogens
Y. pestis is a Gram-negative bacterium belonging to the enterobacteria family. This bacterium can be cultured easily on ordinary media, and exhibits common characteristic of enterobacteria in addition to a specific biochemical profile which can be used for its phenotypic identification. Comparative genetic studies have demonstrated that Y. pestis likely evolved by reductive evolution from Yersinia pseudotuberculosis.27 Several biovars have been described, but their classification is currently
Clinical manifestations
Inoculation via a flea bite can cause a skin lesion that is not usually reported. Depending on the site of inoculation, infection of the regional lymph node that drains the inoculation site may be observable (bubo) when the bite is on the trunk. Inoculation through the skin after handling a plague-infected animal also results in bubonic fever. Inhalation results primary in pneumonia, and ingestion (mostly camel meat or liver)1 results in pharyngitis with cervical buboes. The buboes due to
Routine clinical studies
Routine chest radiographs do not reveal specific elements.39 Blood analysis may be very informative. Most patients have hyperleucocytosis, and 50% have a white blood cell count over 20,000/mm3. In contrast, half of patients have thrombocytopenia. The association of hyperleucocytosis with thrombocytopenia is relatively rare and may be a good indicator of plague.34 Interestingly, in many patients, eosinophilia is observed during convalescence.34
Diagnosis
Three diagnostic clues can make it possible to reach a diagnosis quickly and to start specific treatment.26
- 1.
The existence of fever after contact with dead rodents in a zone where this zoonosis exists.
- 2.
The existence of unexplained adenitis with fever and hypotension.
- 3.
Pneumonia with bloody expectoration and gram-negative bacilli in the sputum.
These characteristics indicate a diagnosis of plague, even in zones where plague is thought to have disappeared (such as in Algeria).18, 19 The examination of
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