Case Report

Ulceroglandular Tularemia in a Nonendemic Area

Authors: M Brad Guffey, MD, Alex Dalzell, MD, David R. Kelly, MD, Kevin A. Cassady, MD

Abstract

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. The cases illustrate how mode of acquisition (direct versus vector-mediated) influences the clinical manifestations of ulceroglandular tularemia. In addition, a brief review of the epidemiology, differential diagnosis, clinical manifestations, and treatment of tularemia is provided.


Key Points


* We report two pediatric patients diagnosed with ulceroglandular tularemia who had been treated unsuccessfully for acute lymphadenitis.


* The cases illustrate some of the differences seen following arthropod-mediated vs. direct inoculation of Francisella tularensis.


* Tularemia, while not endemic in many areas of the southeastern US, nonetheless must be included in the differential diagnosis for ulceroglandular disease.


* The manuscript provides a brief review of the microbiology, diagnosis, clinical manifestations and treatment of tularemia.


* A diagnosis of tularemia, especially in a nonendemic area, should alert the clinician to possible bioterrorism exposure.

This content is limited to qualifying members.

Existing members, please login first.

If you have an existing account please login now to access this article or view your purchase options.

Purchase only this article ($15)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1. Centers for Disease Control and Prevention. Tularemia: United States, 1990–2000. MMWR Morb Mortal Wkly Rep 2002;51:181–184.
 
2. Amsden JR, Warmack S, Gubbins PO. Tick-borne bacterial, rickettsial, spirochetal, and protozoal infectious diseases in the United States: a comprehensive review. Pharmacotherapy 2005;25:191–210.
 
3. Baldwin CJ, Panciera RJ, Morton RJ, et al. Acute tularemia in three domestic cats. J Am Vet Med Assoc 1991;199:1602–1605.
 
4. Centers for Disease Control and Prevention. Tularemia transmitted by insect bites: Wyoming, 2001–2003. MMWR Morb Mortal Wkly Rep 2005;54:170–173.
 
5. Hornick R. Tularemia revisited. N Engl J Med 2001;345:1637–1639.
 
6. Dembek ZF, Buckman RL, Fowler SK, et al. Missed sentinel case of naturally occurring pneumonic tularemia outbreak: lessons for detection of bioterrorism. J Am Board Fam Pract 2003;16:339–342.
 
7. Weinberg AN. Commentary: Wherry WB, Lamb BH: Infection of man with Bacterium tularense. J Infect Dis 1914;15:331–40. J Infect Dis 2004;189:1317–1320.
 
8. Ohara Y, Sato T, Homma M. Arthropod-borne tularemia in Japan: clinical analysis of 1,374 cases observed between 1924 and 1996. J Med Entomol 1998;35:471–473.
 
9. Ohara S. Studies on yato-byo (Ohara’s disease, tularemia in Japan): I. Jpn J Exp Med 1954;24:69–79.
 
10. Uhari M, Syrjala H, Salminen A. Tularemia in children caused by Francisella tularensis biovar palaearctica. Pediatr Infect Dis J 1990;9:80–83.
 
11. Quan SF, McManus AG, Von Fintel H. Infectivity of tularemia applied to intact skin and ingested in drinking water. Science 1956;123:942–943.
 
12. Evans ME, Gregory DW, Schaffner W, et al. Tularemia: a 30-year experience with 88 cases. Medicine (Baltimore) 1985;64:251–269.
 
13. Shapiro DS, Schwartz DR. Exposure of laboratory workers to Francisella tularensis despite a bioterrorism procedure. J Clin Microbiol 2002;40:2278–2281.
 
14. Cerny Z. Changes of the epidemiology and the clinical picture of tularemia in Southern Moravia (the Czech Republic) during the period 1936–1999. Eur J Epidemiol 2001;17:637–642.
 
15. Pike RM. Laboratory-associated infections: summary and analysis of 3921 cases. Health Lab Sci 1976;13:105–114.
 
16. Centers for Disease Control and Prevention. Case definitions for infectious conditions under public health surveillance. MMWR Recomm Rep 1997;46:1–55.
 
17. Koskela P, Salminen A. Humoral immunity against Francisella tularensis after natural infection. J Clin Microbiol 1985;22:973–979.
 
18. Johansson A, Berglund L, Eriksson U, et al. Comparative analysis of PCR versus culture for diagnosis of ulceroglandular tularemia. J Clin Microbiol 2000;38:22–26.
 
19. Enderlin G, Morales L, Jacobs RF, et al. Streptomycin and alternative agents for the treatment of tularemia: review of the literature. Clin Infect Dis 1994;19:42–47.
 
20. Cross JT, Jacobs RF. Tularemia: treatment failures with outpatient use of ceftriaxone. Clin Infect Dis1993;17:976–980.
 
21. Cross JT Jr, Schutze GE, Jacobs RF. Treatment of tularemia with gentamicin in pediatric patients. Pediatr Infect Dis J 1995;14:151–152.
 
22. Dennis DT, Inglesby TV, Henderson DA, et al. Tularemia as a biological weapon: medical and public health management. JAMA 2001;285:2763–2773.
 
23. Russell P, Eley SM, Fulop MJ, et al. The efficacy of ciprofloxacin and doxycycline against experimental tularaemia. J Antimicrob Chemother 1998;41:461–465.
 
24. Feldman KA, Enscore RE, Lathrop SL, et al. An outbreak of primary pneumonic tularemia on Martha’s Vineyard. N Engl J Med 2001;345:1601–1606.
 
25. Siret V, Barataud D, Prat M, et al. An outbreak of airborne tularaemia in France, August 2004. Euro Surveill 2006;11:50–60.
 
26. Jensen WA, Kirsch CM Tularemia. Semin Respir Infect 2003;18:146–158.
 
27. Christopher GW, Cieslak TJ, Pavlin JA, et al. Biological warfare: a historical perspective. JAMA 1997;278:412–417.
 
28. Jacobs RF. Tularemia. Adv Pediatr Infect Dis 1996;12:55–69.
 
29. Franz DR, Jahrling PB, Friedlander AM, et al. Clinical recognition and management of patients exposed to biological warfare agents. JAMA 1997;278:399–411.
 
30. Kaufmann AF, Meltzer MI, Schmid GP. The economic impact of a bioterrorist attack: are prevention and postattack intervention programs justifiable? Emerg Infect Dis 1997;3:83–94.
 
31. Jacobs RF, Condrey YM, Yamauchi T. Tularemia in adults and children: a changing presentation. Pediatrics 1985;76:818–822.