SECTION 2
BIOLOGICAL WEAPON SYNDROMIC CROSS-REFERENCES
Fever with Prominent Arthralgias
Disease/Agent | Incubation | Initial Symptoms |
Blastomycosis(Blastomyces dermatitidis) see page 42 | 30–45 days | Sudden onset of fever, chills, myalgia, arthralgia, cough, and fatigue. 60% develop productive cough, hemoptysis, pleuritic chest pain, low-grade fever, dyspnea, and chest x-ray findings of infiltrates, nodules and/or cavitations. Hilar adenopathy may also be present. |
Brucellosis (Brucella suis & melitensis) see page 46 | Days to months | Intermittent fever, chills, sweats, headache, myalgia, arthralgias, back pain, generalized weakness, malaise, anorexia, nausea, vomiting, diarrhea and/or constipation. Cough and pleuritic chest pain in up to 20% of patients. Chest x-ray is variable and may show hilar adenopathy, pleural effusion nodules, abscesses, and/or bronchopneumonia. |
Chikungunya (Alphavirus) see page 48 | 1–12 days | Abrupt onset of high fever, chills, severe headache, retro-orbital pain, flushing of face and trunk followed by a maculopapular rash of trunk and extremities, and migratory small joint arthralgias (hands, wrists, ankles, & feet primarily) which may be severe. A dengue hemorrhagic fever-like syndrome may occur rarely, especially in children. |
Coccidioidomycosis (Coccidioides immitis) see page 52 | 7–21 days | Fever, dry cough, dyspnea, chest pain, and fatigue. Weight loss, migratory arthralgias, and headache are also common. Chest x-ray often demonstrates unilateral infiltrates, effusions, and hilar adenopathy. Pulmonary nodules and cavitations may also be seen occasionally. Rash is common, with early fine papular, nonpruritic rash that progressing to erythema nodosum and/or erythema multiforme (consider this diagnosis in the triad of fever, erythema nodosum, and arthralgias). May progress to superficial maculopapular lesions, cutaneous ulcers, subcutaneous abscesses, and/or lymphadenopathy. |
Dengue fever and dengue hemorrhagic fever (DHF) (Flavivirus) see page 56 | 3–7 days | Sudden onset of fever, chills, malaise, arthralgias, myalgias, severe frontal headache, flushing, prominent low back pain, and dysesthesia of the skin. May also include prostration, gastrointestinal symptoms, hepatitis, macular or scarlatiniform rash, petechiae, and mucosal bleeding. May progress to DHF with hypotension, restlessness, diaphoresis, diffuse petechiae and ecchymosis, mucosal and gastrointestinal bleeding, ascites, organomegaly, cyanosis, and sudden shock. |
Kyasanur Forest disease (Flavivirus) see page 68 | 2–9 days | Sudden onset of fever, chills, headache, vomiting, severe prostration, pains in arms and legs, flushing of face (no rash), conjunctival suffusion, hepatosplenomegaly, petechiae, general lymphadenopathy, and relative bradycardia. 40% of cases will develop gastrointestinal and mucosal bleeding, and/or hemorrhagic pulmonary edema. 50% of patients develop neurologic sequelae following 1–3 week afebrile period. |
Omsk hemorrhagic fever (Flavivirus) see page 79 | 2–9 days | Sudden onset of fever, chills, headache, arthralgias, severe prostration, pains in arms and legs, flushing of face and trunk (no rash), conjunctival suffusion, papulovesicular eruption on soft palate, cervical lymphadenopathy, and relative bradycardia. GI and mucosal bleeding, and petechiae may occur. Neurologic sequelae or rarely pneumonia may occur late. |
*Remittent fevers are those that go up and down without ever returning to normal, as opposed to intermittent fevers, which are elevated with irregular returns to normal, and relapsing fevers, which are elevated with regular returns to normal.
Acute Hepatic Syndrome
Disease/Agent | Incubation | Initial Symptoms |
Anatoxins (Aspergillus species) see page 36 | Days to weeks | Acute hepatic necrosis with fever, jaundice, edema of the limbs, abdominal pain, nausea, vomiting, pulmonary edema, GI hemorrhaging, hepatomegaly, seizures, coma, and death. |
Crimean-Congo hemorrhagic fever (Bunyaviridae) see page 54 | 7–12 days | Sudden onset of fever, malaise, generalized weakness, back pain, and asthenia. May progress to fulminant disease with hepatitis, jaundice, DIC, shock, extensive bleeding, and death. |
Ebola & Marburg viral hemorrhagic fevers (Filoviridae) see page 59 | 3–14 days | Sudden onset of fever, chills, headache, myalgia, generalized weakness, prostration, cough, sore throat, and conjunctivitis. May progress to nausea, vomiting, diarrhea, abdominal pain, photophobia, maculopapular rash, DIC, internal and external hemorrhages, multiorgan failure with jaundice and renal insufficiency, death. |
Dengue fever and Dengue hemorrhagic fever (DHF) (Flavivirus) see page 56 | 3–7 days | Sudden onset of fever, chills, malaise, myalgias, severe frontal headache, flushing, prominent low back pain, and dysesthesia of the skin. May also include prostration, GI symptoms, hepatitis, macular or scarlatiniform rash, petechiae, and mucosal bleeding. May progress to DHF with hypotension, restlessness, diaphoresis, diffuse petechiae and ecchymosis, mucosal and GI bleeding, ascites, organomegaly, cyanosis, and sudden shock. |
Leptospirosis (Leptospira species) see page 74 | 3–30 days | Sudden onset of remittent fever,* chills or rigors, headache, myalgia, low back pain, and conjunctival injection. May also include cough, abdominal pain, nausea, vomiting, diarrhea, sore throat, and/or a pretibial maculopapular rash. May progress to high fever, hepatitis, jaundice, liver failure, acute renal failure, hemorrhagic pneumonitis with hemoptysis, ARDS, bleeding diathesis, cardiac arrhythmias, shock, and death. |
Q fever (Coxiella burnetii) see page 84 | 2–14 days | High fever, chills, malaise, fatigue, headache, anorexia, and myalgias. May progress to atypical pneumonia or hepatitis. |
Ricin (castor bean extract) & abrin (rosary pea extract) see page 86 | 4–8 hr | Abdominal pain, nausea, vomiting, gastrointestinal hemorrhage with hematemesis and hematochezia. May progress to necrosis of the liver, spleen and/or kidneys, and shock. |
Rift Valley fever (Bunyaviridae) see page 88 | 7–12 days | Sudden onset of fever, malaise, generalized weakness, back pain, and asthenia. May progress to fulminant disease with hepatitis, jaundice, DIC, shock, extensive bleeding, and death. Blindness and/or a fatal encephalitis may occur rarely. |
*Remittent fevers are those that go up and down without ever returning to normal, as opposed to intermittent fevers, which are elevated with irregular returns to normal, and relapsing fevers, which are elevated with regular returns to normal. ARDS = acute respiratory distress syndrome; DIC = disseminated intravascular coagulation; GI = gastrointestinal
Hemorrhagic Diathesis
Disease/Agent | Incubation | Initial Symptoms |
Aflatoxins (Aspergillus species) see page 36 | Days to weeks | Acute hepatic necrosis with fever, jaundice, edema of the limbs, abdominal pain, nausea, vomiting, pulmonary edema, GI hemorrhaging, hepatomegaly, seizures, coma, and death. |
Crimean-Congo hemorrhagic fever (Bunyaviridae) see page 54 | 7–12 days | Sudden onset of fever, malaise, generalized weakness, back pain, and asthenia. May progress to fulminant disease with hepatitis, jaundice, DIC, shock, extensive bleeding, and death. |
Chikungunya (Alphavirus) see page 48 | 1–12 days | Abrupt onset of high fever, chills, severe headache, retro-orbital pain, flushing of face and trunk followed by a maculopapular rash of trunk and extremities, and migratory small joint arthralgias (hands, wrists, ankles & feet primarily), which may be severe. A dengue hemorrhagic fever-like syndrome may occur rarely, especially in children. |
Dengue fever and dengue hemorrhagic fever (DHF) (Flavivirus) see page 56 | 3–7 days | Sudden onset of fever, chills, malaise, arthralgias, myalgias, severe frontal headache, flushing, prominent low back pain, and dysthesia of the skin. May also include prostration, GI symptoms, hepatitis, macular or scarlatiniform rash, petechiae, and mucosal bleeding. May progress to DHF with hypotension, restlessness, diaphoresis, diffuse petechiae and ecchymosis, mucosal and GI bleeding, ascites, organomegaly, cyanosis, and sudden shock. |
Ebola & Marburg viral hemorrhagic fevers (Filoviridae) see page 59 | 3–14 days | Sudden onset of fever, chills, headache, myalgia, generalized weakness, prostration, cough, sore throat, and conjunctivitis. May progress to nausea, vomiting, diarrhea, abdominal pain, photophobia, maculopapular rash, DIC, internal and external hemorrhages, and multiorgan failure. |
Hantavirus hemorrhagic fever with renal syndrome see page 64 | 5–24 days | Sudden onset of fever, chills, myalgias, headache, dizziness, low back pain, abdominal pain, conjunctival injection, blurred vision, erythematous rash on trunk and face, petechiae over upper trunk and on soft palate, and sudden severe shock and death. Survivors develop 3–10 days of mucosal bleeding, oliguria or anuria, hypertension, pneumonitis, and/or pulmonary edema. |
Kyasanur Forest disease (Flavivirus) see page 68 | 2–9 days | Sudden onset of fever, chills, headache, vomiting, severe prostration, pains in arms and legs, flushing of face (no rash), conjunctival suffusion, hepatosplenomegaly, petechiae, general lymphadenopathy and relative bradycardia. 40% of cases will develop GI and mucosal bleeding and/or hemorrhagic pulmonary edema. 50% of patients develop neurologic sequelae following 1–3 week afebrile period. |
Lassa virus & the South American viral hemorrhagic fevers (Arenaviruses) see page 70 | 3–19 days | Fever, malaise, myalgia, dysesthesia, abdominal pain, chest pain, back pain, sore throat, headache, vomiting, cough, photophobia, conjunctival injection, and flushing of face and upper trunk. May progress to hypotension, facial edema, pulmonary edema, vesicular and/or petechiae rash of oropharynx, mucosal hemorrhages, and occasionally pleural effusion, ascites. |
Leptospirosis (Leptospira species) see page 74 | 3–30 days | Sudden onset of remittent fever,* chills or rigors, headache, myalgia, low back pain, and conjunctival injection. May also include cough, abdominal pain, nausea, vomiting, diarrhea, pharyngitis, and/or a pretibial maculopapular rash. May progress to high fever, liver failure, acute renal failure, aseptic meningitis, hemorrhagic pneumonitis with hemoptysis, ARDS, bleeding diathesis, cardiac arrhythmias, shock, and death. |
2–9 days | Sudden onset of fever,* chills, headache, severe prostration, pains in arms and legs, flushing of face and trunk (no rash), conjunctival suffusion, papulovesicular eruption on soft palate, cervical lymphadenopathy, and relative bradycardia. GI and mucosal bleeding, and petechiae may occur. Neurologic sequelae or rarely pneumonia may occur late. | |
Ricin (castor bean extract) & abrin (rosary pea extract) see page 86 | 4–8 hr | Abdominal pain, nausea, vomiting, gastrointestinal hemorrhage with hematemesis and hematochezia. May progress to necrosis of the liver, spleen, and/or kidneys, and shock. |
Rift Valley fever (Bunyaviridae) see page 88 | 7–12 days | Sudden onset of fever, malaise, generalized weakness, back pain, and asthenia. May progress to fulminant disease with hepatitis, jaundice, DIC, shock, extensive bleeding, and death. Blindness and/or a fatal encephalitis may occur rarely. |
*Remittent fevers are those that go up and down without ever returning to normal, as opposed to intermittent fevers, which are elevated with irregular returns to normal, and relapsing fevers, which are elevated with regular returns to normal. ARDS = acute respiratory distress syndrome; DIC = disseminated intravascular coagulation; GI = gastrointestinal
Hilar Adenopathy or Widened Mediastinum
Disease/Agent | Incubation | Initial Symptoms |
Anthrax, inhalational (Bacillus anthracis) see page 38 | 1–6 days | 24–48 hr of fever (or recent history of fever), chills, cough, malaise, headache, myalgias, and possible chest tightness. Malaise may be profound and notable. Mediastinal widening or hilar adenopathy, and/or pleural effusion on CXR. Progresses to high fever, extreme fatigue, nonproductive cough, dyspnea, severe respiratory distress, cyanosis, septicemia, and death. |
Blastomycosis (Blastomyces dermatitidis) see page 42 | 30–45 days | Sudden onset of fever, chills, myalgia, arthralgia, cough, and fatigue. 60% develop productive cough, hemoptysis, pleuritic chest pain, low-grade fever, dyspnea, and CXR findings of infiltrates, nodules, and/or cavitations. Hilar adenopathy may also be present. |
Brucellosis (Brucella suis & melitensis) see page 46 | Days to months | Intermittent fever, chills, sweats, headache, myalgia, arthralgias, back pain, generalized weakness, malaise, anorexia, nausea, vomiting, diarrhea and/or constipation. Cough and pleuritic chest pain in up to 20% of patients. CXR is’variable and may show hilar adenopathy, pleural effusion nodules, abscesses, and/or bronchopneumonia. |
Coccidioidomycosis (Coccidioides immitis) see page 52 | 7–21 days | Fever, dry cough, dyspnea, chest pain, and fatigue. Weight loss, migratory arthralgias and headache are also common. CXR often demonstrates unilateral infiltrates, effusions, and hilar adenopathy. Pulmonary nodules and cavitations may also be seen occasionally. Rash is common, with early fine papular, nonpruritic rash progressing to erythema nodosum and/or erythema multiforme (consider this diagnosis in the triad of fever, erythema nodosum, and arthralgias). May progress to superficial maculopapular lesions, cutaneous ulcers, subcutaneous abscesses, and/or lymphadenopathy. |
Tularemia (pneumonic) (Francisella tularensis) see page 106 | 11–21 days | Sudden onset of high fever, chills, cough, prostration, headache, and substernal chest pain. Possible superficial regional adenopathy. Progresses to dyspnea, possible hemoptysis, tracheitis, bronchitis, pleural effusions, and/or pneumonia. Hilar adenopathy may be present on CXR. Can lead to respiratory failure and lung abscess. |
CXR = chest x-ray
Fever with Petechiae
Disease/Agent | Incubation | Initial Symptoms |
Dengue fever and Dengue hemorrhagic fever (DHF) (Flavivirus) see page 56 | 3–7 days | Sudden onset of fever, chills, malaise, arthralgias, myalgias, severe frontal headache, flushing, prominent low back pain, and dysesthesia of the skin. Often includes prostration, GI symptoms, hepatitis, macular or scarlatiniform rash, petechiae, and mucosal bleeding. May progress to DHF with hypotension, restlessness, diaphoresis, diffuse petechiae and ecchymosis, mucosal and GI bleeding, ascites, organomegaly, cyanosis, and sudden shock. |
Hantavirus hemorrhagic fever with renal syndrome see page 64 | 5–24 days | Sudden onset of fever, chills, myalgias, headache, dizziness, low back pain, abdominal pain, conjunctival injection, blurred vision, erythematous rash on trunk and face, petechiae over upper trunk and on soft palate, and sudden severe shock and death. Survivors develop 3–10 days of mucosal bleeding, oliguria or anuria, hypertension, pneumonitis, and/or pulmonary edema. |
Kyasanur Forest disease (Flavivirus) see page 68 | 2–9 days | Sudden onset of fever, chills, headache, vomiting, severe prostration, pains in arms and legs, flushing of face (no rash), conjunctival suffusion, hepatosplenomegaly, petechiae, general lymphadenopathy and relative bradycardia. 40% of cases will develop GI and mucosal bleeding, and/or hemorrhagic pulmonary edema. 50% of patients develop neurologic sequelae following 1–3 week afebrile period. |
Lassa virus & the South American viral hemorrhagic fevers (Arenaviruses) see page 70 | 3–19 days | Fever, malaise, dizziness, myalgia, dysesthesia, abdominal pain, chest pain, back pain, sore throat, headache, vomiting, cough, photophobia, conjunctival injection, flushing of face and upper trunk, and possible axillary petechiae. May progress to hypotension, facial edema, pulmonary edema, vesicular and/or petecheal rash of oropharynx, mucosal hemorrhages, and occasional pleural effusion and/or ascites. |
Omsk hemorrhagic fever (Flavivirus) see page 79 | 2–9 days | Sudden onset of fever, chills, headache, severe prostration, pains in arms and legs, flushing of face and trunk (no rash), conjunctival suffusion, papulovesicular eruption on soft palate, cervical lymphadenopathy, and relative bradycardia. GI and mucosal bleeding, and petechiae may occur. Neurologic sequelae or rarely pneumonia may occur late. |
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