Yersinia pestis infection differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]; Alison Leibowitz [3]

The differential diagnosis for yersina pestis infection is dependent on the clinical syndrome (bubonic plague, septicimic plague, pneumonic plague, or pharyngeal plague). Bubonic plague should be differentiated from other causes of lymphadenopathy, such as streptococcal or staphylococcal lymphadenitis, infectious mononucleosis, cat-scratch fever, and tularemia. Septicemic plague should be differentiated from non-specific sepsis syndrome and gram negative sepsis. The differential diagnosis for pneumonic plague includes infections that cause community-acquired pneumonia, such as pneumococcal or streptococcal pneumonia, viral pneumonia, hemophilus influenzae, and anthrax.^[1]

Conditions that also cause lymphadenopathy:^[1]

• Streptococcal or staphylococcal adenitis (Staphylococcus aureus, Staphylococcus pyogenes)
  • Purulent or inflamed lesion often noted distal to involved nodes (ie, pustule, infected traumatic lesion)
  • Involved nodes more likely to be fluctuant
  • Associated ascending lymphangitis or cellulitis may be present (generally not seen with plague)

• Infectious mononucleosis

• Tularemia (Francisella tularensis)
  • Ulcer or pustule often present distal to involved nodes
  • Clinical course rarely as fulminant as in plague
  • Systemic toxicity uncommon

• Cat scratch fever (Bartonella henselae)
  • History of contact with cats; usually history of cat scratch
  • Indolent clinical course; progresses over weeks
  • Primary lesion at site of scratch often present (small papule, vesicle)
  • Systemic toxicity not present

• Mycobacterial infection, including scrofula (Mycobacterium tuberculosis and other Mycobacterium species)
  • With scrofula, adenitis occurs in cervical region
  • Usually painless
  • Indolent clinical course
  • Infections with species other than M tuberculosis more likely to occur in immunocompromised patients

• Lymphatic filariasis
• Tick typhus

Conditions that also cause intra-abdominal lymphadenopathy:^[1]

• Appendicitis
• Acute cholecystitis
• Enterocolitis

Condition that also causes inguinal lymphadenopathy:^[1]

• Lymphogranuloma venereum (Chlamydia trachomatis)
  • Adenitis occurs in the inguinal region
  • History of sexual exposure 10-30 days previously
  • Suppuration, fistula tracts common
  • Although LGV buboes may be somewhat tender, exquisite tenderness usually absent
  • Although patients may appear ill (headache, fever, myalgias), systemic toxicity not present

• Chancroid (Haemophilus ducreyi)
  • Adenitis occurs in the inguinal region
  • Ulcerative lesion present
  • Systemic symptoms uncommon; toxicity does not occur

• Primary genital herpes
  • Herpes lesions present in genital area
  • Adenitis occurs in the inguinal region
  • Although patients may be ill (fever, headache), severe systemic toxicity not present

• Primary or secondary syphilis (Treponema pallidum)
  • Enlarged lymph nodes in the inguinal region
  • Lymph nodes generally painless
  • Chancre may be noted with primary syphilis

• Strangulated inguinal hernias
  • Evidence of bowel involvement

Conditions that manifest similarly:

• Non-specific sepsis syndrome
• Gram negative sepsis^[1]

Pneumonic plague should be differentiated from the following diseases:

• Inhalational anthrax (Bacillus anthracis)
  • Widened mediastinum and pleural effusions seen on CXR or chest CT
  • Not true pneumonia; minimal sputum production
  • Hemoptysis uncommon (if present, suggests diagnosis of plague)

• Tularemia (Francisella tularensis)
  • Clinical course not as rapid or fulminant as in pneumonic plague

• Mycoplasmal pneumonia (Mycoplasma pneumoniae)
  • Rarely as fulminant as pneumonic plague

• Pneumonia caused by Chlamydia pneumoniae
  • Rarely as fulminant as pneumonic plague

• Legionnaires’ disease (Legionella pneumophila or other Legionella species)
  • Rarely as fulminant as pneumonic plague
  • Community outbreaks of Legionnaires’ disease often involve exposure to cooling systems
  • Legionellosis and many other diseases caused by bacterial agents (S aureus, S pneumoniae, H influenzae, K pneumoniae, M catarrhalis) usually occur in persons with underlying pulmonary or other disease or in the elderly

• Psittacosis (Chlamydia psittaci)
  • Rarely as fulminant as pneumonic plague
  • Result of bird exposure

• Other bacterial agents (eg, Staphyloccocus aureus, Streptococcus pneumoniae, Haemophilus influenzae, Klebsiella pneumoniae, Moraxella catarrhalis)
  • Rarely as fulminant as pneumonic plague
  • Usually occur in persons with underlying pulmonary or other disease or in the elderly

• Influenza
  • Influenza generally seasonal (October-March in United States) or involves history of recent cruise ship travel or travel to tropics

• Hantavirus
  • Exposure to excrement (urine or feces) of mice with Hantavirus

• RSV
  • RSV usually occurs in children (although may be cause of pneumonia in elderly); tends to be seasonal (winter/spring)

• CMV
  • CMV usually occurs in immunocompromised patients

• Q fever (Coxiella burnetii)
  • Exposure to infected parturient cats, cattle, sheep, goats
  • Severe pneumonia not prominent feature

• Leptospirosis

• Hantavirus pulmonary syndrome

• viral pneumonia

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