A clinical study of bubonic plague. Observations of the 1970 Vietnam epidemic with emphasis on coagulation studies, skin histology and electrocardiograms

Clinical features of forty patients with bacteriologically-proved bubonic plague are described. Adolescents with severe clinical illness predominated. All patients were treated with streptomycin; only one patient died. Fifteen patients were toxic and had a higher mean white cell count, a lower mean platelet count and a higher mean serum glutamic oxaloacetic transaminase level (SGOT) than the others. Eleven patients had evidence for disseminated intravascular coagulation (DIC) based on low platelet counts, prolonged partial thromboplastin times and positive ethanol gelation tests. Skin biopsy specimens from two of these with purpura revealed intravascular fibrin thrombi in dermal vessels. Two patients had electrocardiograms showing right axis deviation that suggested acute cor pulmonale. These findings of laboratory evidence for DIC, fibrin thrombi in purpuric lesions and acute cor pulmonale are explained by known actions of endotoxin and support the concept that endotoxin by mediating a generalized Shwartzman reaction plays a major role in the pathogenesis of plague.