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Tularemia

Rabbit Fever

Tularemia is a condition that severely affects the eyes, skin, lymph nodes and the lungs. It is an infectious disease caused by the bacterium Francisella tularensis.


Presentation

The symptoms of tularemia usually develop 3 – 5 days after exposure to the bacterium. The signs and symptoms of the disease include the following [7]:

These are some of the common signs and symptoms experienced. However, symptoms may be different for different forms of tularemia. For example, in case of pneumonic tularemia, individuals suffer from cough, difficulty in breathing and shortness of breath. In case of typhoidal tularemia, in addition to above mentioned symptoms, individuals also experience pneumonia, enlarged spleen and liver, extreme exhaustion and vomiting along with diarrhea.

Cervical Lymphadenopathy
  • OBJECTIVE: Tularemia can cause cervical lymphadenopathy.[ncbi.nlm.nih.gov]
  • This case report details the clinical manifestation and course of glandular tularemia, an uncommon but significant cause of cervical lymphadenopathy in children.[ncbi.nlm.nih.gov]
  • OPT may cause tonsillopharyngitis followed by cervical lymphadenopathies (LAPs). Without treatment LAP may persist for several months and may mimic other diseases causing cervical LAPs.[ncbi.nlm.nih.gov]
  • In this report, we describe a child treated for Hodgkin's disease presenting six years later with a left cervical lymphadenopathy mimicking a relapse.[ncbi.nlm.nih.gov]
  • Herein, we describe a girl with tularemia who presented with right cervical lymphadenopathy and left nasopharyngeal mass.[ncbi.nlm.nih.gov]
Axillary Lymphadenopathy
  • Case Report A 60-year-old woman was admitted to our hospital with a week history of sudden onset of cutaneous lesion on the second finger in her right hand, accompanied by fever, chills, headache and axillary lymphadenopathy.[omicsonline.org]
  • Case 3: We described another 20-year-old female patient with a tick bite in her right hand occurring 5 months before consultation, followed by fever, chills and regional painful axillary lymphadenopathy ( Lübbert et al., 2009 ).[frontiersin.org]
Inguinal Lymphadenopathy
  • Glandular tularemia should be considered in the differential diagnosis of inguinal lymphadenopathy.[ncbi.nlm.nih.gov]
Generalized Lymphadenopathy
  • lymphadenopathy : due to a systemic infection of the body e.g., influenza or secondary syphilis Persistent generalized lymphadenopathy (PGL): persisting for a long time, possibly without an apparent cause By localization: Hilar lymphadenopathy.[en.wikipedia.org]
Fever
  • Pahvant Valley plague rabbit fever deer fly fever Ohara's fever edit English tularemia primary bacterial infectious disease that has material basis in Francisella tularensis, which is transmitted by dog tick bite (Dermacentor variabilis), transmitted[wikidata.org]
  • Tick-borne Rickettsia rickettsii Rocky Mountain spotted fever Rickettsia conorii Boutonneuse fever Rickettsia japonica Japanese spotted fever Rickettsia sibirica North Asian tick typhus Rickettsia australis Queensland tick typhus Rickettsia honei Flinders[en.wikipedia.org]
  • He had recurrence of fever and diarrhea. He was treated with ciprofloxacin (500 mg twice daily, oral, for 14 days) and symptoms resolved.[ncbi.nlm.nih.gov]
Pain
  • Oculoglandular form: Patients have painful, red eyes, often with a yellow discharge and crusting. Swollen glands may occur in the jaw, neck or around the ear.[dph.illinois.gov]
  • We present a case of a 7-year-old male who presented with a painful right-sided palpable neck mass for 9 days, who was diagnosed with Tularemia after numerous admissions.[ncbi.nlm.nih.gov]
  • Symptoms of tularemia include an abrupt onset of fever, chills, headache, muscle aches, joint pain, dry cough, difficulty breathing, bloody sputum and respiratory failure.[dailycamera.com]
  • Symptoms may include coughing, chest pain, and breathing problems. Fluid may build up around the lung, or lung abscesses may occur. Typhoidal: This type is a general form of tularemia whose symptoms include fever, joint pain, and malaise.[my.clevelandclinic.org]
Chills
  • A 37-year-old man presented with a 4-day history of nonbloody diarrhea, fever, chills, productive cough, vomiting, and more recent sore throat. He worked for the municipality in a village in the Swiss Alps near St. Moritz.[ncbi.nlm.nih.gov]
  • A positive association was found between MAT and fever (r 0.324; p 0.001), and a negative association was found between MAT and both lymphoadenopathy (r -0.25; p 0.013) and chills (r -0.218; p 0.035).[ncbi.nlm.nih.gov]
  • The disease is characterized by a sudden onset with high fever, headache, malaise, chills, myalgia, and arthralgia. A short time after exposure, an inflamed and ulcerated lesion rapidly appears at the site of entry.[ncbi.nlm.nih.gov]
  • Symptoms: The common symptoms of tularemia include fever, chills, muscle aches, stiffness in the joints, sweating, breathing difficulty and weight loss.[symptoma.com]
  • Typhoidal (septicemic) form : Bacteria in the bloodstream produces fevers, chills, muscle pain or tenderness, lack of energy and weight loss. The absence of an ulcer or swollen glands can make diagnosis difficult.[dph.illinois.gov]
Hunting
  • We report on a 13-year-old patient who developed ulceroglandular tularemia after having assisted in slaughtering a hunted boar. He presented with a digital skin ulcer and enlarged lymph nodes.[ncbi.nlm.nih.gov]
  • In Japan, most tularemia cases occur after contact with hares (hunting, cooking) and involve the glandular or ulceroglandular form.[ncbi.nlm.nih.gov]
  • Caution is urged to anyone who may come in contact with wild animals, especially those who might hunt or eat wild hogs.[today.ttu.edu]
  • In particular, this can occur when hunting or skinning infected rabbits, muskrats, prairie dogs and other rodents. Many other animals have also been known to become ill with tularemia.[cdc.gov]
  • People should also wear insect repellent in outdoor areas and prevent pets from hunting wild rodents and rabbits. There were five cases of tularemia in Boulder County in 2014.[dailycamera.com]
Malaise
  • Two patients present with the abrupt onset of fever, malaise, anorexia, fatigue, progressive skin lesions and lymphadenitis. These patients represent two of the six cases of tularemia reported in Alabama over the last decade.[ncbi.nlm.nih.gov]
  • The disease is characterized by a sudden onset with high fever, headache, malaise, chills, myalgia, and arthralgia. A short time after exposure, an inflamed and ulcerated lesion rapidly appears at the site of entry.[ncbi.nlm.nih.gov]
  • Tularemia was suspected because of the rabbit exposure; however, other common diseases characterized by fever, malaise, and lymphadenopathy of acute onset were also considered (ie, ehrlichiosis and Rocky Mountain spotted fever).[ncbi.nlm.nih.gov]
  • Cats with a history of fever, malaise, icterus, and anorexia but no lesions characteristic of tularemia and/or negative immunohistochemistry, no isolation of bacteria in bacterial culture, and less than 4-fold raise in serum antibody titer for F. tularensis[ncbi.nlm.nih.gov]
  • Typhoidal: This type is a general form of tularemia whose symptoms include fever, joint pain, and malaise. It may be hard to find out how the infection entered the body. This type affects the bloodstream and major organs.[my.clevelandclinic.org]
Exudative Pharyngitis
  • Tularemia: an unappreciated cause of exudative pharyngitis. Pediatrics 1976 Dec;58(6):864-6 [ Abstract ] Urich SK, Petersen JM. In vitro susceptibility of isolates of Francisella tularensis types A and B from North America.[cidrap.umn.edu]
  • pharyngitis or tonsillitis; abdominal pain, nausea, and vomiting; cervical lymphadenopathy; diarrhea; gastrointestinal bleeding Intestinal tularemia - Abdominal pain, vomiting, and diarrhea Pneumonic tularemia - Dry cough, dyspnea, and pleuritic-type[emedicine.com]
Tachycardia
  • Examination showed fever (40 C), hypotension, tachycardia, tachypnea, decreased oxygen saturation (90 % at room air), and bibasilar crackles and wheezing.[ncbi.nlm.nih.gov]
Hepatomegaly
  • Typhoidal tularemia This rare and serious form of the disease usually causes: High fever Extreme exhaustion Vomiting and diarrhea Enlarged spleen (splenomegaly) Enlarged liver (hepatomegaly) Pneumonia When to see a doctor If you think you may have been[mayoclinic.org]
Red Eye
  • Oculoglandular form: Patients have painful, red eyes, often with a yellow discharge and crusting. Swollen glands may occur in the jaw, neck or around the ear.[dph.illinois.gov]
  • When the infection enters through the eyes, it results in swollen and red eyes with tender lymph glands in front of the ears. In many cases, tularemia is seen as a combination of several of these symptoms.[healthychildren.org]
  • Oculoglandular tularemia This form affects the eyes and may cause: Eye pain Eye redness Eye swelling and discharge An ulcer on the inside of the eyelid Sensitivity to light Oropharyngeal tularemia Usually caused by eating poorly cooked wild animal meat[mayoclinic.org]
Periorbital Edema
  • In addition, involvement of larynx, oropharynx, and retropharynx; presence of periorbital edema; and neck abscess formation were evaluated using CECT.[ncbi.nlm.nih.gov]
  • In the oculoglandular form, fever, lymphadenopathy, periorbital edema, conjunctival injection, and chemosis were found. The most distinctive ophthalmic feature was follicular conjunctivitis and conjunctival epithelial defects.[ncbi.nlm.nih.gov]
Myalgia
  • The disease is characterized by a sudden onset with high fever, headache, malaise, chills, myalgia, and arthralgia. A short time after exposure, an inflamed and ulcerated lesion rapidly appears at the site of entry.[ncbi.nlm.nih.gov]
  • Some individuals may develop the typhoidal form of tularemia in which fever, myalgias, and general ill health (malaise) develop without accompanying skin lesions or lymphadenopathy.[rarediseases.org]
  • The studied patient had an ulceroglandular form, defined by a painful maculopapular or ulcerate lesion in the spot where the bacteria entered the body, regional lymphadenopathies and systemic symptoms like fever, chills or myalgias.[omicsonline.org]
  • […] local lymph nodes Chills Prostration Conjunctivitis Diaphoresis Axillary adenopathy Non-Productive Cough Hemoptysis Pt usually presents w/ what appears to be community acquire pneumonia, however it does not respond to conventional treatment Headache Myalgias[physio-pedia.com]
  • Typhoidal tularemia Fever with no localizing signs Sepsis Headaches Myalgias Diarrhea 6.[cancertherapyadvisor.com]
Arthralgia
  • The disease is characterized by a sudden onset with high fever, headache, malaise, chills, myalgia, and arthralgia. A short time after exposure, an inflamed and ulcerated lesion rapidly appears at the site of entry.[ncbi.nlm.nih.gov]
  • Despite treatment with amoxicillin–clavulanic acid, her symptoms worsened and fever, chills, headache, and arthralgias developed. Funding and Disclosures This case was presented at the Medical Case Conference, May 1, 2009. Dr.[nejm.org]
  • Characteristics/Clinical Presentation [4] [5] [6] [3] [1] Fever Abdominal pain Arthralgias Shortness of breath Malaise Nausea/Vomiting Sore throat Tender local lymph nodes Chills Prostration Conjunctivitis Diaphoresis Axillary adenopathy Non-Productive[physio-pedia.com]
  • Most cases of tularemia begin with rapid onset of nonspecific, flu-like symptoms including fever, chills, headaches, muscle pain (myalgia), joint pain (arthralgia), loss of appetite, and a general feeling of ill health (malaise).[rarediseases.org]
  • All patients had fever and most of them had general symptoms such as headache, myalgia, and arthralgia. Dry cough was reported in one-half of the cases, and a similar proportion had retrosternal discomfort, pleural pain or dyspnoea.[erj.ersjournals.com]
Skin Ulcer
  • He presented with a digital skin ulcer and enlarged lymph nodes. Clinically suspected tularemia was proven by real-time polymerase chain reaction performed on a skin ulcer biopsy and swab and by positive serology.[ncbi.nlm.nih.gov]
  • Signs and Symptoms Skin ulcer of tularemia. Photo courtesy of the CDC Public Health Image Library/Emory University, Dr. Sellars.[columbia-lyme.org]
  • There are six main types of tularemia with different effects: Ulceroglandular form: Patients have a skin ulcer(s) and swollen tender glands. Glandular form : Patients have swollen glands without a skin ulcer.[dph.illinois.gov]
  • Ulceroglandular Tularemia The symptoms of ulceroglandular tularemia, or infection through the skin, can include: a skin ulcer at the point of contact with the infected animal or at the site of a bite swollen lymph nodes near the skin ulcer (most often[healthline.com]
Erythema
  • Erythema multiforme was found in 17 patients (11.3%), most of whom presented with the oropharyngeal and glandular forms, and was followed by ulcer (6.0%), urticaria (3.3%), erythema nodosum (2.6%), and cellulitis (0.7%).[ncbi.nlm.nih.gov]
  • We present the case of an 11-year old girl who presented with erythema multiforme minor in the setting of an indolent but progressive soft tissue infection and was found to have tularemia.[ncbi.nlm.nih.gov]
  • The second case was admitted with erythema nodosum, and abdominal lymphadenopathy was detected during the investigation. Excisional lymph node biopsy revealed abdominal tularemia.[ncbi.nlm.nih.gov]
  • However, the frequencies of erythema, tenderness, and fluctuant of enlarged lymph nodes were significantly higher in the adult group than in the pediatric group (P 0.005, P 0.029, and P 0.041, respectively).[ncbi.nlm.nih.gov]
  • Erythema multiforme is a common finding in all forms of tularemia. Other dermatological manifestations are urticarial, erythema nodosum and cellulitis [ 7 ].[omicsonline.org]
Neck Mass
  • Lymphadenopathy excision was performed on 19.4% of patients in whom neck mass persisted.[ncbi.nlm.nih.gov]
  • We present a case of a 7-year-old male who presented with a painful right-sided palpable neck mass for 9 days, who was diagnosed with Tularemia after numerous admissions.[ncbi.nlm.nih.gov]
  • The purpose of this report is to present a tularemia case accompanied by a neck mass that easily may be confounded with dental abscess. Francisella tularensis is a potential agent of biologic terrorism.[ncbi.nlm.nih.gov]
  • In this article, we describe a case of zoonotic tularemia that manifested as a neck mass, and we review the pathophysiology, diagnosis, and treatment of tularemia. We also summarize what is known about its potential as a biological weapon.[ncbi.nlm.nih.gov]
  • A total of six cases with head and neck mass following a story of tonsillopharyngitis admitted to different clinics including infectious diseases, ear-nose-throat and internal medicine in our tertiary care hospital.[ncbi.nlm.nih.gov]
Facial Swelling
  • In this present case, a 51-year-old woman arrived at the public health department with high fever and facial swelling. The findings suggested a dental origin and the patient was directed to dentistry.[ncbi.nlm.nih.gov]
Headache
  • The disease is characterized by a sudden onset with high fever, headache, malaise, chills, myalgia, and arthralgia. A short time after exposure, an inflamed and ulcerated lesion rapidly appears at the site of entry.[ncbi.nlm.nih.gov]
  • Moderate systemic reactogenicity (mostly headache or feeling tired) was reported by 23% of participants receiving either vaccine. Injection site reactogenicity was mostly mild itchiness and pain.[ncbi.nlm.nih.gov]
  • […] illness (fever, chills, headache, etc.)[centerforhealthsecurity.org]
  • Symptoms of tularemia include an abrupt onset of fever, chills, headache, muscle aches, joint pain, dry cough, difficulty breathing, bloody sputum and respiratory failure.[dailycamera.com]
  • If inhaled, symptoms can include sudden onset of fever, chills, headache, muscle aches, joint pain, dry cough and weakness. The disease does not spread from person to person and can be treated with antibiotics.[nj.gov]

Workup

It often gets difficult to diagnose tularemia, the reason being that the disease shares some common signs and symptoms with other diseases. The following tests are carried out to diagnose the disease condition [8]:

  • Blood tests: Blood tests and culture are done for identifying the causative bacterium. Serology tests would also be required in order to measure the immune response to infections.
  • Chest X-ray: This is done to check for signs of pneumonia.
  • In addition to blood tests and chest X-ray, polymerase chain reaction (PCR) test is also carried out from sample of an ulcer.
Decreased Oxygen Saturation
  • Examination showed fever (40 C), hypotension, tachycardia, tachypnea, decreased oxygen saturation (90 % at room air), and bibasilar crackles and wheezing.[ncbi.nlm.nih.gov]
Francisella Tularensis
  • Macrophage Infected with Francisella tularensis Bacteria (5950310835).jpg 611 640; 104 KB Riproduci file multimediale Rapid-dissemination-of-Francisella-tularensis-and-the-effect-of-route-of-infection-1471-2180-8-215-S1.ogv 6,7 s, 768 1 104; 7,34 MB Riproduci[commons.wikimedia.org]
  • METHODS: The Serazym Anti-Francisella tularensis ELISA, Serion ELISA classic Francisella tularensis IgG/IgM, an in-house ELISA, the VIRapid Tularemia immunochromatographic test, an in-house antigen microarray, and a Western Blot (WB) assay were evaluated[ncbi.nlm.nih.gov]
  • Article First Online: 19 May 2016 Abstract Francisella tularensis is the causative agent of the potentially lethal disease tularemia.[doi.org]
  • Tularemia is a zoonotic disease caused by Francisella tularensis.[ncbi.nlm.nih.gov]
  • Survival of Francisella tularensis Type A in brackish-water. Arch Microbiol. 2011;193(3):223-6 [ Abstract ] Birdsell DN, Stewart T, Vogler AJ, et al. Francisella tularensis subsp. novicida from a human in Arizona.[cidrap.umn.edu]

Treatment

  • Antibiotics form the preliminary basis of treatment regime. Various antibiotics such as gentamicin or streptomycin are administered for treating the condition of tularemia [9]. These antibiotics may either be given intravenously or orally. Based on the type of tularemia that has set in, different types of antibiotics may also be given.
  • In case of accompanying complications, affected individuals may also receive additional therapy for the same. After an attack of tularemia, individuals may develop immunity against it. However, there have been many instances, when individuals may suffer from recurrent bouts of the disease [10].

Prognosis

When treatment is not given, then the disease turns fatal in about 5% cases. However, when promptly treated, the condition can successfully resolve. The mortality rate is higher in individuals suffering from typhoidal tularemia. In addition to delay in diagnosis and typhoidal tularemia, there are several other factors that increase the chances of mortality in individuals. These include renal failure and elevated levels of creatine kinase [6].

Etiology

Humans are not directly infected by the bacteria that cause tularemia. But, it spreads to humans by the mammals infected by Francisella tularensis. The following are the ways through which humans get infected through the bacterium [2]:

Epidemiology

Tularemia is a common occurrence in the western and southern regions of the US. It has been estimated that annually, 200 cases of tularemia are reported to occur in the US. In the past, the condition occurred more frequently during the winter months. However, the incidence pattern has changed and frequency of tularemia has increased during warm weather. Statistics have revealed that, during the years 1990 – 2000, about 56% cases were reported in areas of Oklahoma, Arkansas, South Dakota and Missouri [4].

Sex distribution
Age distribution

Pathophysiology

For the bacteria to cause an infection, it must first gain entry into the human body. This primarily occurs through insect bites or through inhalation. Once it enters the body, there is development of an ulcer at the site of wound or bite. It takes about 2 to 4 days for the ulcer to develop. In cases, when the bacteria enter the body through inhalation, it spreads through the lymph nodes causing infection. The infection that occurs, produces an inflammatory response that particularly involves the neutrophils, local macrophages and fibrin [5].

Prevention

The following measures can be taken to prevent attack of tularemia:

  • Insect bites are the most common route for transmission of the bacterium. Individuals are advised to wear long sleeved clothing when they visit tick infected areas.
  • During gardening, individuals are advised to wear face mask while working with the soil.
  • It is necessary to wear gloves and other protective clothing while handling wild animals such as rabbits, or hares.
  • It is also necessary to protect the pets from insect bites or prevent them from feeding on diseased animals. This would prevent them from contracting the bacteria and developing tularemia.
  • Several attempts have been made to prepare the tularemia vaccine; however, attempts were not successful [11].

Summary

Tularemia is also known as deer fly fever. It primarily affects the mammals such as hares, rodents and rabbits. In certain cases, it can also affect the reptiles, fishes and birds. Humans are affected through insect bites or when they are directly exposed to infected animals. It is a highly infectious disease, though rare, but extremely fatal. If diagnosed in the early stages, it can be successfully treated with antibiotics [1].

Patient Information

  • Definition: Tularemia is an infectious disease which is common amongst the wild rodents. Humans can get infected through contact with tissues of infected animals. The condition is also known as deer fly fever. Tularemia is a common occurrence in parts of North America and Northern Eurasia. 
  • Cause: Tularemia is caused by the bacterium Francisella tularensis. The bacteria primarily infect the rodents and wild animals, which is later on transmitted to the humans. Humans can get infected by the bacteria through insect bites, consumption of contaminated water or undercooked meat of diseased animal, breathing in infected plant material or soil and direct contact with the bacteria during handling animals.
  • Symptoms: The common symptoms of tularemia include fever, chills, muscle aches, stiffness in the joints, sweating, breathing difficulty and weight loss. When the lungs are affected, individuals can develop pneumonia and can experience chest pain as well. Affected individuals get exhausted easily and also experience shortness in breath.
  • Diagnosis: Blood tests and blood culture will help to identify the causative organisms. Sputum culture would also aid in diagnosis of tularemia. In addition, chest X-ray would also provide useful insight about pneumonia and other associated complications.
  • Treatment: Antibiotics are given for treatment of tularemia. Depending on severity of the condition, antibiotics are administered either orally or intravenously.

References

Article

  1. Tarnvik A, Berglund L. Tularemia. EurRespir J. 2003;21:361-73.
  2. Centers for Disease Control and Prevention (CDC). Tularemia - Missouri, 2000-2007. MMWR Morb Mortal Wkly Rep 2009; 58:744.
  3. Thomas LD, Schaffner W. Tularemia pneumonia. Infect Dis Clin North Am 2010; 24:43.
  4. Tularemia--Oklahoma, 2000. MMWR Morb Mortal Wkly Rep. Aug 24 2001;50(33):704-6.
  5. Geyer SJ, Burkey A, Chandler FW.Tularemia. In: Connor DH. Pathology of Infectious Diseases. Stamford, CT: Appleton & Lange; 1997:869-73.
  6. Penn RL, Kinasewitz GT. Factors associated with a poor outcome in tularemia. Arch Intern Med 1987; 147:265.
  7. Jensen WA, Kirsch CM. Tularemia. SeminRespir Infect. Sep 2003;18(3):146-58.
  8. Tärnvik A, Chu MC.New approaches to diagnosis and therapy of tularemia. Ann N Y AcadSci 2007; 1105:378.
  9. Hassoun A, Spera R, Dunkel J. Tularemia and once-daily gentamicin. Antimicrob Agents Chemother 2006; 50:824.
  10. Thomas LD, Schaffner W. Tularemia pneumonia. Infect Dis Clin North Am. Mar 2010;24(1):43-55.
  11. Mann BJ, Ark NM. Rationally designed tularemia vaccines. Expert Rev Vaccines 2009; 8:877.

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Last updated: 2019-07-11 22:40