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Updated: Dec 23 2021


  • 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.)
    • 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
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