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]:

• Fever accompanied by chills
• Development of conjunctivitis
• Unexplained weight loss
• Pain in muscles along with experiencing stiffness in joints
• Headache 
• Difficulty in breathing
• Sweating

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]

• Lymph Node Tenderness

  Symptoms and Types Sudden onset of fever Lethargy Dehydration Lack of appetite (anorexia) Enlargement of the lymph nodes Tender abdomen Enlargement of spleen or liver White patches or ulcers on the tongue Jaundice – may be indicated by yellow eyes Causes [petmd.com]

• 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

  […] will cause lymph nodes in the neck on that same side to swell up Generalized 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 [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]

  Tularemia Other names Tularaemia, Pahvant Valley plague,[1] rabbit fever,[1] deer fly fever, Ohara's fever[2] A tularemia lesion on the back of the right hand Specialty Infectious disease Symptoms Fever, skin ulcer, large lymph nodes[3] Causes Francisella [en.wikipedia.org]

  CONCLUSION: Appropriate empiric antibiotherapy should be commenced in patients presenting with neck mass, fever, and lethargy in regions with tularemia epidemics. [ncbi.nlm.nih.gov]

• Pain

  An eye becomes painful, swollen, and red, and pus often oozes from it. Nearby lymph nodes become swollen and painful. [merckmanuals.com]

  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]

• Chills

  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]

  The clinical onset of tularemia is typically abrupt, with fever greater than 101°F, headache, myalgias, fatigue, chills, vomiting, sore throat, and abdominal pain. [accutixdx.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]

  Symptoms: The common symptoms of tularemia include fever, chills, muscle aches, stiffness in the joints, sweating, breathing difficulty and weight loss. [symptoma.com]

• Lymphadenopathy

  To the best of our knowledge, these are the firstly described abdominal lymphadenopathy cases from Turkey. The second case was admitted with erythema nodosum, and abdominal lymphadenopathy was detected during the investigation. [ncbi.nlm.nih.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]

  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]

  Protect your pets and hunting dogs by preventing them from hunting or eating wild animals. Infected pets may in turn transmit the disease to you (especially house cats that may bite if they’re not feeling well and you try to help them). [wgfd.wyo.gov]

  An increase is also seen during the winter rabbit hunting season, in areas where this is a common practice. [petmd.com]

• Pharyngitis

  Ingestion typically results in oropharyngeal tularemia, with fever, pharyngitis, cervical lymphadenitis, and suppuration ( Figure 1 ). [wwwnc.cdc.gov]

  Francisella tularensis is a small Gram-negative aerobic intracellular bacterium that should be considered as a possible pathogen in patients with fever, pharyngitis, and lymphadenopathia. [ncbi.nlm.nih.gov]

  Pharyngeal disease can be misdiagnosed as Group A streptococcal pharyngitis, mononucleosis, adenoviral pharyngitis, or diphtheria. [infectiousdiseaseadvisor.com]

• Pleural Effusion

  As is the case with tuberculous pleural effusions, pleural fluid in tularemia showed an abundance of lymphocytes, predominantly CD4-positive T lymphocytes. [ncbi.nlm.nih.gov]

  effusion Studies Labs culture is hazardous positive titers on serology diagnostic Making the diagnosis based on clinical presentation, risk factors, and serology Differential Cat-scratch disease distinguishing factor lymphadenopathy with papular, pustular [medbullets.com]

• Tachypnea

  Examination showed fever (40 °C), hypotension, tachycardia, tachypnea, decreased oxygen saturation (90 % at room air), and bibasilar crackles and wheezing. [ncbi.nlm.nih.gov]

• Nausea

  Snapshot A 40-year-old woman presents to the emergency room for acute-onset fever, nausea, vomiting, and diarrhea. She works as a veterinarian tech in rural Colorado. [medbullets.com]

  General symptoms include fever, headache, chills, nausea, and muscle and joint pain. [extension.entm.purdue.edu]

  […] in rickettsial infections have now been recorded, and aureomycin perhaps exerts its greatest influence in this group of diseases. 3 Favorable results from its employment in lymphogranuloma inguinale have been published. 4 No toxic effects other than nausea [jamanetwork.com]

  Oropharyngeal form: From eating undercooked infected meat, this form is associated with a sore throat, stomach pain, nausea, vomiting, diarrhea and occasionally stomach bleeding. [dph.illinois.gov]

• Abdominal Pain

  Here, we present a case of typhoidal tularemia in a 72-year-old Japanese male farmer who presented with fever, fatigue, and right lower abdominal pain. [ncbi.nlm.nih.gov]

  Some people also have abdominal pain, nausea, vomiting, and diarrhea. Oropharyngeal tularemia is usually caused by eating undercooked contaminated meat or drinking contaminated water. [merckmanuals.com]

  pain, diarrhea, and vomiting pneumonia How it would be spread Aerosol or food. [pbs.org]

• Hepatomegaly

  Presentation Symptoms ulceroglandular headache painful conjunctivitis pharyngitis typhoidal nausea vomiting Physical exam high fever ulceroglandular tender maculopapular rash initially lesion may ulcerate with a raised border tender lymphadenopathy typhoidal hepatomegaly [medbullets.com]

  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]

  Clinical signs may include fever, depression, lymphadenopathy, abscesses, oral or lingual ulceration, gastroenteritis, hepatomegaly, splenomegaly, icterus, anorexia, weight loss, pneumonia, and sepsis. [avma.org]

  […] lymphocytes into the parenchyma; degeneration of neutrophils noted. ( J127 .90.w1) In common marmosets experimentally infection by inhalation of Francisella tularensis SCHU S4. ( J626 .59.w1) By 48 hours post-exposure, splenomegaly was present, also slight hepatomegaly [wildpro.twycrosszoo.org]

• Chest Pain

  Pneumonic form: From the inhalation of organisms or by spread from other areas of the body, patients with this form have a dry cough, difficulty breathing and sharp chest pain. [dph.illinois.gov]

  Thousands of enemy soldiers have been exhibiting chest pains, dry coughs, and swollen lymph nodes. To you and your suffering unit, anything that ends this bloody conflict sooner rather than later is welcomed. [study.com]

  A person with pneumonia can develop chest pain, difficulty breathing and respiratory failure. Preventive measures If you have symptoms, please consult a healthcare provider as soon as possible. [doh.wa.gov]

• 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]

  Tachycardia-induced silencing of subcellular Ca2+ signaling in atrial myocytes. J Clin Invest 2014; 124: 4759-4772. 22. [czytelniamedyczna.pl]

• Exudative Pharyngitis

  Oropharyngeal: The oropharyngeal form can present with stomatitis or an exudative pharyngitis or tonsillitis. There may also be ulcers and cervical lymphadenopathy. It may present with cervical nodes resembling the "bull neck" of diphtheria. [visualdx.com]

  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]

  Tender lymphadenopathy without evidence of local cutaneous lesions Oculoglandular tularemia - Unilateral conjunctivitis, corneal ulceration, lymphadenopathy, photophobia, lacrimation, lid edema, vision loss (rare) Oropharyngeal tularemia - Stomatitis and exudative [emedicine.com]

• Conjunctival Injection

  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]

  Typically, a patient has an abrupt onset of fever, headache, chills and rigors, myalgia (especially the low back), coryza, and sore throat. In 42% of patients, a pulse-temperature dissociation has been observed. [visualdx.com]

  The clinical onset of tularemia is typically abrupt, with fever greater than 101°F, headache, myalgias, fatigue, chills, vomiting, sore throat, and abdominal pain. [accutixdx.com]

  It is more severe and patients present with fever, chills, myalgia, malaise and weight loss. Those affected often have pneumonia. Ulcers and lymphadenopathy are usually absent. [patient.info]

• 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]

  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]

  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]

  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]

• Neck Pain

  You have sudden chest pain. You have sudden trouble breathing. You have a severe headache and neck pain. Your symptoms do not improve even after taking antibiotics. Care Agreement You have the right to help plan your care. [drugs.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]

  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. [idph.state.il.us]

• 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]

  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]

• Neck Swelling

  Pharyngeal tularemia presents with a sore throat, fever, and swelling in the neck. The most serious forms of tularemia are typhoidal and pneumonic disease. [emedicinehealth.com]

• 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]

  […] illness (fever, chills, headache, etc.) [centerforhealthsecurity.org]

  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]

  Sudden fever Chills Headaches Diarrhea Muscle aches Joint pain Dry cough Progressive weakness Symptoms vary depending on the method of transmission. See more information on Tularemia. [smcmvcd.org]

  Symptoms include continuously high fever, terrible headache, and confusion. The illness may result in a severely low blood pressure, with signs of poor blood flow to the major organs (shock). [medical-dictionary.thefreedictionary.com]

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.

• Pulmonary Infiltrate

  […] involvement findings pulmonary infiltrates hilar lymphadenopathy pleural effusion Studies Labs culture is hazardous positive titers on serology diagnostic Making the diagnosis based on clinical presentation, risk factors, and serology Differential Cat-scratch [medbullets.com]

• Pyuria

  Sterile pyuria may be observed. White blood cell counts and erythrocyte sedimentation rate may be normal or slightly elevated. Serum transaminases are not elevated, although serum CPK may be increased in typhoidal tularemia. [accutixdx.com]

  Pyuria can also be observed. Aspiration of pleural fluid usually reveals lymphocytes suggesting the diagnosis of tuberculosis. Gram stains of the sputum and skin lesions are usually unrevealing. [infectiousdiseaseadvisor.com]

• Francisella Tularensis

  Article First Online: 19 May 2016 Abstract Francisella tularensis is the causative agent of the potentially lethal disease tularemia. [doi.org]

  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]

  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]

  Comparative proteome analysis of cellular proteins extracted from highly virulent Francisella tularensis ssp. tularensis and less virulent F. tularensis ssp. holarctica and F. tularensis ssp. mediaasiatica. Proteomics. 2004, 10, 3048-60. [mmsl.cz]

• Pleural Effusion

  As is the case with tuberculous pleural effusions, pleural fluid in tularemia showed an abundance of lymphocytes, predominantly CD4-positive T lymphocytes. [ncbi.nlm.nih.gov]

  effusion Studies Labs culture is hazardous positive titers on serology diagnostic Making the diagnosis based on clinical presentation, risk factors, and serology Differential Cat-scratch disease distinguishing factor lymphadenopathy with papular, pustular [medbullets.com]

• 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].

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].

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]:

• Insect bites or mosquito bite
• Direct exposure to infected animals and or insects
• Consumption of contaminated water or improperly cooked meat
• Breathing in dust or soil containing the bacterium can cause pneumonic tularemia [3]

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].

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].

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].

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].

• 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.

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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.
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8. Tärnvik A, Chu MC.New approaches to diagnosis and therapy of tularemia. Ann N Y AcadSci 2007; 1105:378.
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11. Mann BJ, Ark NM. Rationally designed tularemia vaccines. Expert Rev Vaccines 2009; 8:877.