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. She frequently treats exotic pets and wildlife refugees, involving injured rabbits and muskrats. On physical exam, she is severely febrile. There is also tenderness to palpation in the abdomen and hepatosplenomegaly. She is started on antibiotics. Introduction Classification Francisella tularensis an aerobic gram - coccobacilli transmission hosts include ticks, rabbits, and deer flies bites from exposed animals inhalation of organism Associated conditions ulceroglandular tularemia (most common) typhoidal tularemia pulmonary tularemia may accompany both ulceroglandular (< 50% of cases) or typhoidal (80% of cases) tularemia Epidemiology Incidence rare Demographics south-central United States Risk factors exposure to small mammals (rabbits, voles, muskrats, etc.) ETIOLOGY Pathogenesis inoculation of the skin or mucous membranes leads to spread of organism to the lymph nodes and other organs inhalation may result in pulmonary disease 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 splenomegaly pneumonia Imaging Chest radiography indication suspected pulmonary 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 disease distinguishing factor lymphadenopathy with papular, pustular, or vesicular lesions without ulceration at the site of inoculation Brucellosis distinguishing factor often presents with osteoarticular disease, such as osteomyelitis or arthritis Treatment Complications Renal failure Meningitis Erythema nodosum Prognosis Symptoms arise acutely < 1 week after exposure Patients with pneumonia have the highest mortality