CorrectCare

Biochemical Terrorism: Are You Ready?
by Harvey Hoffman, DO

It was a beautiful Sunday morning in early October, here in Las Vegas. I settled into my favorite chair to read the newspaper. Within minutes my reverie was interrupted. There on the front page was an article dealing with our city’s preparation against the threat of chemical warfare.

“Not again,” I heard myself say. The article stated that all area physicians had been contacted by the local health department and the county disaster preparedness division to begin to coordinate a team approach so as to best assess our chances of recognizing, treating and otherwise coping with any act of biochemical terrorism perpetrated on our area.

“All” physicians? I was accustomed to our jail being omitted from many contingency plans dealing with medical delivery systems in our city. However, when it came to biochemical terrorism, I felt I had to intercede.

First thing Monday I made a flurry of phone calls. Within two days, with the help of several county agencies, our jail went from being omitted to not only hosting the city’s first CDC-sponsored lecture on the agents of biochemical warfare, but also being considered as a centralized location for storage and distribution of emergency medical supplies from the federal government in the event that our area was a target of biochemical warfare.

I presented on this subject at the National Conference on Correctional Health Care in November, in part to encourage others in our profession to make the same appeals to their local governments to obtain this valuable information. Until you do, here are some guidelines to help you in diagnosing potential biochemical agents.

BIOLOGICAL AGENTS

Anthrax

• Cutaneous: Seen on commonly exposed areas such as the face, neck, hands and forearms. First you see localized itching, followed by a papule that forms to a vesicle, then development of a black escar in 7 to 10 days.
• Intestinal: Rare.
  • Upper GI: Oral or esophageal ulceration leading to lymphadenopathy, edema and sepsis.
  • Lower GI: Lesions in the terminal ilium or cecum presenting with nausea or vomiting and malaise, and progressing rapidly to bloody diarrhea, acute abdomen or sepsis.

The usual incubation period is 1 to 5 days, but as long as 60 days with low inoculation exposure. It is typically a biphasic illness. The initial phase will produce flu-like symptoms (no runny nose). The second, or acute, phase will occur 1 to 5 days after initial symptoms (this may be preceded by up to 3 days of improvement), with the abrupt development of severe respiratory distress with dyspnea, stridor, cyanosis and high fever.

The average interval between the acute phase and death is 3 days, which emphasizes the need for fast recognition. Chest x-ray findings of a widened mediastinum with pleural effusion but no infiltrates is highly suspicious for anthrax. A vaccine is available.

Tularemia
In a biological attack, this highly infectious bacteria could be spread through an aerosol release as with anthrax. We are looking at flu-like symptoms. This infection hurts a lot, so people seek medical attention. Skin ulcers with enlarged regional lymph nodes and fever must be diagnosed as tularemia until proven otherwise. Another clue to this illness, as with many of the other agents, is the discovery of clusters of these symptoms within a given population.

Antibiotics usually are effective.

Botulism
Botulism spores are found in the soil worldwide. Intentional exposure could occur through contamination of food or water, or via aerosol. This toxin interferes with neural synapses leading to flaccid paralysis that is bilateral and descending. First comes bilateral cranial neural impairment such as blurred or double vision, ptosis, dysphagia, dry mouth and slurred speech. Then comes paralysis, which, when it progresses to the respiratory muscles, leads to ventilatory failure and death unless supportive care is in use. Botulism antitoxin must be given within hours of exposure to be effective.

VHF
These are the viral hemorrhagic fever viruses, such as Ebola and Marburg, that cause severe, life-threatening diagnoses. Their natural reservoir is never a human. Once contracted, this virus may be spread by close personal contact or by contact with objects contaminated by bodily fluids. Initial signs are flushing, conjunctival injection, periorbital edema and hypotension. This leads quickly to marked fever, total exhaustion, dizziness and muscle aches. Severe cases include signs of bleeding under the skin, in internal organs or from body orifices.

Plague
In the event of a biological attack, the bacteria would be spread through the air. It occurs in humans in three forms.

• Bubonic: The most common form. Symptoms include high fever, chills, severe malaise, headaches, delirium, nausea/vomiting, diarrhea and coma. The most distinctive sign is swelling of the lymph nodes in the groin, axilla and neck. The swollen nodes are called buboes. They become pus-filled and painful, and many rupture and ooze.
• Septic: Similar to bubonic but without the swollen nodes.
• Pneumonic: Incubation period of 1 to 3 days. Presents with sudden onset of headache, malaise, fever, myalgia and cough. A watery cough that turns bloody is pathonomatic for plague. Any form of plague can be fatal if untreated. Antibiotics exist to treat plague, but must be used immediately.

Smallpox
Highly contagious, disfiguring and deadly, this disease is spread person to person. No treatment other than supportive is given. A vaccine does exist. If used by terrorists, it would be in aerosol form. In this form, it makes its way into the nasal passages and lungs. It can also be spread by direct contact with the skin eruptions or by contaminated clothing or linens. The virus appears approximately 2 weeks after exposure.

The diagnosis is marked by the acute onset of fever, malaise, severe headache, vomiting and delirium. The rash begins 2 to 3 days after the onset of fever. It begins in the mouth and throat and spreads to the lower extremities and then the trunk in a period of a week. The affected areas often are permanently scarred. Victims must be isolated for 3 to 4 weeks in a negative air pressure room.

CHEMICAL AGENTS

Cyanide
This agent is highly toxic and in sufficient concentrations rapidly leads to death. Inhalation is the most important route of poisoning. Cyanide inhibits core respiration, which can lead to death. Like all chemical agents, poisoning depends on route, dose and exposure times. The initial symptoms of inhaled cyanide are restlessness, increased respiratory rate, giddiness, headache, palpitations and some breathlessness. Later symptoms are vomiting, convulsions, respiratory failure and unconsciousness. Treatment is based upon speeding cyanide excretion from the body and to binding it in the blood. Sulphur and cobalt compounds are used for this purpose, but must be used immediately.

Mustard Gas
Symptoms do not occur immediately. It may take 24 hours, and by then damage may be extensive. The gas causes blisters and pigmentation to the skin, which may lead to necrosis. Inhalation results in lung damage and injury to the bone marrow, lymphatic tissue and spleen. Exposure leads to a condition very similar to radiation exposure. To decontaminate, wash the victim’s skin with soap and water and flush the eyes with physiologic salt solution for at least 10 minutes. Local anesthetics can be used for pain relief and eye injuries treated with antibiotics.

VX Gas
Very persistent, remaining at ground level for 3 to 4 weeks. Like the other gases, it easily diffuses through human skin, or can be inhaled. At high concentrations the victim has immense suffering, usually crumpling to the ground, losing urine control, experiencing cramps, severe spasms and eventual loss of consciousness. Hospitalization must be immediate to sustain life, and even with survival, permanent damage is frequent.

Theon Gas
This is the easiest gas to make and was used in the Iran-Iraq war by Saddam Hussein. It has the same effects as VX gas and the same immediacy in treatment is required.

Mycotoxins
An attack using these agents should be expected if aerosolized yellow droplets begin to fall from the sky (this is called yellow rain). Death occurs to half of all exposed within 24 hours. Other people will develop a lethal illness called alimentary toxic aleuria. Within days of exposure look for fever, chills, myalgias, bone marrow suppression and secondary sepsis. If the victim still lives, he develops pharyngeal/laryngeal ulceration and diffuse bleeding into the skin along with melena, bloody diarrhea, hematuria, hematemesis, epistaxis and vaginal bleeding. Isolation is not necessary.

Sarin Gas
A nerve agent developed by Nazi Germany, as were most of these gases. It’s readily absorbed by inhalation, ingestion and dermal contact. Symptoms may occur within minutes or hours, depending on dose. Initial effects depend on dose and route of exposure, but look for rhinorrhea, chest tightness, pinpoint pupils, shortness of breath, excessive salivation and sweating, nausea, vomiting, abdominal cramps, diarrhea. Antidotes must be given within minutes to a few hours after exposure. Treatment consists of supportive measures and repeated administration of antidotes.

A FINAL NOTE
Remember: One case is an incident, two is an outbreak. Observation of any unusual clinical presentation should prompt an immediate call to your local health department office of epidemiology. The more informed we are, the greater our ability to save patient lives and, perhaps, our own.

— About the author: Harvey Hoffman, DO, is medical director at the Clark County Detention Center, Las Vegas. He spoke on this subject at the National Conference on Correctional Health Care in November. To purchase an audiotape (session #284), call Nationwide Recording Services, (972) 818-8273, ext. 114, or visit the Web at www.nrstaping.com.

[This article first appeared in the Winter 2002 issue of CorrectCare.]