Plague — DTM&H MCQ

Correct answer: D — Gentamicin or doxycycline with notification

The correct answer is D, gentamicin or doxycycline with notification. This adolescent has classic bubonic plague (Yersinia pestis): rodent contact in an endemic focus (Madagascar), an acutely painful, tender inguinal bubo, high fever, and progression to toxaemia and hypotension suggesting septicaemic spread. Aminoglycosides (gentamicin) or tetracyclines (doxycycline) are bactericidal against Y. pestis and are the first-line agents recommended for treatment of plague, and because plague is a statutorily notifiable disease in the UK, any suspected case must be reported immediately to the local health protection team even if acquired abroad. Prompt antibiotics are life-saving given the risk of rapid progression to septicaemic or secondary pneumonic plague with high mortality if untreated. Why the other options are wrong: E. Cefalexin cream: a topical cephalosporin has no role in systemic Y. pestis infection; the organism requires systemic bactericidal therapy, not skin-directed treatment. B. Praziquantel: this is an antihelminthic used for schistosomiasis and other trematode or cestode infections, with no activity against a bacterial pathogen like Y. pestis. C. Chloroquine: an antimalarial with no antibacterial activity; it does not treat Y. pestis and would leave a toxic, hypotensive patient untreated for a rapidly fatal infection. A. Fluconazole: an antifungal agent, irrelevant to a bacterial bubo and would allow fatal progression of septicaemic plague. Key point: painful bubo plus rodent exposure in an endemic area (Madagascar) with systemic toxicity should trigger immediate gentamicin or doxycycline therapy and statutory notification for suspected plague.

Reference: UK Health Security Agency, 'Plague: epidemiology, outbreaks and guidance', GOV.UK, https://www.gov.uk/guidance/plague-epidemiology-outbreaks-and-guidance