Pediatric Terrorism and Disaster Preparedness: A ... - PHE Home

Signs and symptoms. The incubation period after exposure ranges from 1 to 14 days. Acute and
chronic presentation is possible, but acute illness is most likely after a bioterrorist event. Disease
may be localized (e.g., pneumonia) or disseminated (fulminant sepsis). Most commonly,
symptoms include high fever, mucositis, and abscesses in multiple organs, predominantly the
lungs, liver, and spleen.
Symptoms and signs associated with acute septicemia include fever, rigors, headache, muscle
pain, night sweats, pleuritic chest pain, jaundice, sensitivity to light, and diarrhea. Diffuse
erythroderma may be accompanied by necrotizing lesions. Cervical adenopathy, tachycardia, and
mild hepatomegaly or splenomegaly may be present.
Acute localized disease may involve the lungs (after inhalation of particles or through
hematogenous spread). In addition to the signs and symptoms associated with acute septicemia
(above), miliary lesions and/or bilateral upper lobe infiltrates with or without consolidation or
cavitation may be noted on chest radiograph. Mucous membrane involvement begins with nasal
ulcers and nodules that secrete bloody discharge and often lead to sepsis. A papular and/or
pustular rash, similar in appearance to the smallpox rash, may develop. Liver and spleen
abscesses may be present. Septic shock usually follows.
Diagnosis. Small bacilli may be seen on methylene blue or Wright stain of exudates. Both B.
mallei and B. pseudomallei can be grown and identified from standard cultures.
Treatment and prophylaxis. Without effective antibiotic therapy, mortality nears 100%.
Localized disease may be treated successfully with oral therapy for 60-150 days, while systemic
illness requires parenteral therapy. Definitive antibiotic therapy should be based on susceptibility
testing. Presumptive therapy can be provided using amoxicillin/clavulanate (60 mg/kg/day, PO,
divided TID), tetracycline (40 mg/kg/day, PO, divided TID), or trimethoprim-sulfamethoxazole
(trimethoprim 4 mg/kg/day; sulfamethoxazole 20 mg/kg/day, PO, divided BID) for localized
disease.
The effectiveness of prophylactic, postexposure therapy is not known. Trimethoprimsulfamethoxazole
may be tried.
Control measures. Person-to-person transmission is unlikely after inhalational exposure as
would be expected in disease due to terrorism. Transmission from direct contact between
nonintact skin or mucous membranes and infected animal tissue is the usual means of natural
infection. Standard precautions are adequate for most patients, while contact precautions should
be added for patients with skin lesions. Environmental decontamination using 0.5% hypochlorite
solution (bleach) is effective.
Reporting. If glanders is suspected, contact your local and State health departments. If they are
unavailable, contact the CDC at 770-488-7100.
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