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Bioterrorism Therapy-lnduced lmmunodeficiencies Although diagnosis of primary immunodeficiencies is relatively rare in adults, secondary immunodeficiencies are quite com- mon. Thble 36lists select medications causing secondary immu- nodefi ciencies, related infections, and preventive measures. Bioterrorism lntrodustion Unusually severe illness, rapid increase in disease incidence, atypical clinical presentation, and uncommon geographic, temporal, or demographic clustering of disease outbreaks sug- gest a bioterrorism attack. Bioterrorism agents are classified (table 37) according to ease of dissemination, mortality rate, potential for public panic and social disruption, and need for special action for public health preparedness. Anthrax F I G U R E 27 , A, "box-car"-shaped, gram-positive Bacillus anthracis bacilli in the cerebrospinal fluid of the index case of inhalational anthrax resulting from bioterrorism Anthrax infection is caused by Bacillus anthracis spores in the United States; B, terminal and subterminal spores of B. anthracis; C, black eschar (Figure 27 panel A and Figure 27 panel B). Spores may be lesion of cutaneous anthrax; D, chest radiograph of a patient with anthrax showing a spread by aerosolization or in the mail, with infection fol- widened mediastinum caused by hemorrhagic lymphadenopathy.

Anthrax F I G U R E 27 , A, "box-car"-shaped, gram-positive Bacillus anthracis bacilli in the cerebrospinal fluid of the index case of inhalational anthrax resulting from bioterrorism Anthrax infection is caused by Bacillus anthracis spores in the United States; B, terminal and subterminal spores of B. anthracis; C, black eschar (Figure 27 panel A and Figure 27 panel B). Spores may be lesion of cutaneous anthrax; D, chest radiograph of a patient with anthrax showing a spread by aerosolization or in the mail, with infection fol- widened mediastinum caused by hemorrhagic lymphadenopathy. lowing inhalation; any case of inhalation anthrax must be considered potential bioterrorism. Infection may also occur forming (Figure 27 panel C), or by ingestion. Person-to- by cutaneous contact, with a characteristic black eschar person transmission does not occur. Clinical features are described in Table 38. Meningitis TABLE 37" PotentialAgents of Bioterrorism occurs in up to 50% of persons. Rapid clinical deterioration Class A" Class Bb Class C' leads to shock and death. Radiographic imaging reveals a wid- Anthrax O fever Emerging ened mediastinum (Figure 27 panel D). Diagnosis is made by infectious culture or polymerase chain reaction (PCR) of blood, tissues, Botulism Brucellosis diseases or fluid samples. Plague Glanders Nipah virus Treatment is outlined in Table 38. Postexposure prophylaxis Smallpox Melioidosis Hantavirus consists of a fluoroquinolone or doxycycline in conjunctionwith Tularemia Viral encephalitis vaccination or monoclonal antibodies when alternative preven- Novel influenza Viral hemorrhagic Typhus fever virus tive therapies cannot be used or are unavailable. fever Ricin toxin I(EY PO I ilTS Filoviruses (Ebola, Staphylococcal o Any case of inhalational anthrax should be considered Marburg) enterotoxin B potential bioterrorism. Arenaviruses Psittacosis (Lassa, o Patients with inhalational anthrax infection present Machupo) Foodborne illness Salmonella, with malaise, myalgia, fever, cough, dyspnea, and sub- Escherichia coli sternal chest discomfort; radiographic imaging reveals a 0157:H7 , Shigella widened mediastinum. Waterborne illness CnJptosporidium parvum,Vibrio cholerae Smallpox (Variola) "Greatest potential for use in an attack, easy dissemination, high mortality, and Routine smallpox vaccination ceased in 1980, after the World profound public health implications. Health Organization declared the disease eradicated, leaving bless easily spread, fewer illnesses and deaths, fewer public health preparation much of the world's population without immunity. Following measures required. inhalation, multiplication in regional lymph nodes results in cPotential to be engineered for future mass dissemination and significant mortality viremia.

lowing inhalation; any case of inhalation anthrax must be considered potential bioterrorism. Infection may also occur forming (Figure 27 panel C), or by ingestion. Person-to- by cutaneous contact, with a characteristic black eschar person transmission does not occur. Clinical features are described in Table 38. Meningitis TABLE 37" PotentialAgents of Bioterrorism occurs in up to 50% of persons. Rapid clinical deterioration Class A" Class Bb Class C' leads to shock and death. Radiographic imaging reveals a wid- Anthrax O fever Emerging ened mediastinum (Figure 27 panel D). Diagnosis is made by infectious culture or polymerase chain reaction (PCR) of blood, tissues, Botulism Brucellosis diseases or fluid samples. Plague Glanders Nipah virus Treatment is outlined in Table 38. Postexposure prophylaxis Smallpox Melioidosis Hantavirus consists of a fluoroquinolone or doxycycline in conjunctionwith Tularemia Viral encephalitis vaccination or monoclonal antibodies when alternative preven- Novel influenza Viral hemorrhagic Typhus fever virus tive therapies cannot be used or are unavailable. fever Ricin toxin I(EY PO I ilTS Filoviruses (Ebola, Staphylococcal o Any case of inhalational anthrax should be considered Marburg) enterotoxin B potential bioterrorism. Arenaviruses Psittacosis (Lassa, o Patients with inhalational anthrax infection present Machupo) Foodborne illness Salmonella, with malaise, myalgia, fever, cough, dyspnea, and sub- Escherichia coli sternal chest discomfort; radiographic imaging reveals a 0157:H7 , Shigella widened mediastinum. Waterborne illness CnJptosporidium parvum,Vibrio cholerae Smallpox (Variola) "Greatest potential for use in an attack, easy dissemination, high mortality, and Routine smallpox vaccination ceased in 1980, after the World profound public health implications. Health Organization declared the disease eradicated, leaving bless easily spread, fewer illnesses and deaths, fewer public health preparation much of the world's population without immunity. Following measures required. inhalation, multiplication in regional lymph nodes results in cPotential to be engineered for future mass dissemination and significant mortality viremia. 57