Case Report

Ulceroglandular Tularemia in a Nonendemic Area

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


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.

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