Tularemia

 

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Original Editors - Dana Collins from Bellarmine University's Pathophysiology of Complex Patient Problems project.

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Definition/Description

Tularemia, named after the infectious gram-negative bacterium Francisella tularensis, is a zoonotic disease. A zoonotic disease is one that is spread from animal to human. This spread may be directly i.e. handling contaminated meat or through a carrier i.e. a tick. It is also known as “Ohara’s disease”, “rabbit fever”, “deer-fly fever”, “market’s men disease”, “meat-cutter’s disease”, “glandular type of tick fever”, “water rat-trappers’ disease”. It is highly infectious, <10 organisms causing severe disease in both humans and animals. There are 4 sub-types of the bacterium, the most common in the United States are Type A, tularenis, and Type B, holarctica. It is on the Center for Disease Control’s list of bioterroism threats.

http://www.youtube.com/watch?feature=player_detailpage&v=zUVQB39ATME

Prevalence

The prevalence of Tularemia in the United States depends on the geographical location and the time of year. During the spring and summer months (May-September), there is a rise in reported cases. South-Central, Pacific Northwest, and parts of the East Coast have the highest incidence of Tularemia. While the population most effected is young males 5-9 years old and those > 75 years old.

The above images from: http://www.cdc.gov/tularemia/statistics/.

Characteristics/Clinical Presentation

Fever Abdominal pain Arthralgias Shortness of breath Malaise Nausea/Vomiting Sore throat Tender local lymph nodes

Chills Prostration Conjunctivitis Diaphoresis Axillary adenopathy Non-Productive Cough Hemoptysis Pt usually presents w/ what appears to be community acquire pneumonia, however it does not respond to conventional treatment

Headache Myalgias Cutaneous ulcers Weight loss Epitrochlear adenopathy Pleuritic chest pain, retrosternal pain Painful skin lesion @ site of infection (ulceroglandular only)

Note: The 2 most common forms are glandular/ulcerglandular and pneumonic.
Those occurring in ≥25% of those infected with the glandular and ulceroglandular form are in bold
Those occurring in ≥25% of those infected with the pneumonic form are in italics           

Image from
http://images.google.com/imgres?imgurl=http://pathmicro.med.sc.edu

Ulcer on Thumb

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Image:Tularemia_Lymph.jpg

Image from:

http://images.google.com/imgres?imgurl=http://www.cdc.gov/ncidod/eid/vol8no1/images/01-01311b.jpg&imgrefurl=http://www.cdc.gov/ncidod/eid/vol8no1/01-0131G1.htm&usg=__RtpWetpDIct3b5_CJBM8pgr_-nU=&h=470&w=450&sz=20&hl=en&start=0&sig2=dKSVIceXFPloTF8jaLHe9w&zoom=1&tbnid=xb8CAxcw88AiTM:&tbnh=145&tbnw=146&ei=xbJ2TcXzHoTNqwGat_CKCQ&prev=/images%3Fq%3Dtularemia%26hl%3Den%26biw%3D1579%26bih%3D755%26tbs%3Disch:1&itbs=1&iact=hc&vpx=536&vpy=245&dur=865&hovh=152&hovw=146&tx=140&ty=115&oei=xbJ2TcXzHoTNqwGat_CKCQ&page=1&ndsp=28&ved=1t:429,r:9,s:0

Expectations/Prognosis

Untreated: Fatality ~5%

Treated: Fatality <1%

Poor outcomes have been associated with those who have underlying co-morbidities such as alcoholism or diabetes and those who delay seeking medical treatment.

Medications

Antibiotic therapy is used to treat Tularemia. Streptomyocin and Gentamicin are usually the first administered. Ciprofloxacin along with other fluoroquinolones. Tetracycline and chloramphenicol may also be used to treat Tularemia, however they have higher relapse rates than the previously mentioned.

Resistant to beta-lactam antibiotics and azithromycin.

Diagnostic Tests/Lab Tests/Lab Values

There are numerous ways to test for F. tularensis:
• Gold Standard: Bacteriologic Culture
• Most Common: Serology
• PCR of sample ulcer
• Direct Stains
• Blood Culture
• Direct Fluorescent Antibody Stain
• Slide Agglutination
• Antimicrobial Susceptibility
• Biochemical Identification
• Enviornmental Specimen Evaluation
• Chest X-ray

Etiology/Causes

Direct transmission occurs from direct contact with the infected animal or direct contact from soil, water, or landscape. This may be from ingestion of contaminated meat (most likely rabbit), water, or inhaled dust. It can also be passed from handling or skinning contaminated animals or from a bite/scrath from a contaminated animal. Animal hosts that may spread Tularemia include lagomorphs (rabbit and hare), rodents, insectivores, carnivores, ungulates, marsupials, birds, amphibians, fish, and invertebrates. Secondary carriers include ticks, mosquitoes, biting flies or deerfly. With such a wide variety of hosts and carriers available of this disease, it is has the possibility to appear/outbreak in other regions.

Systemic Involvement ,

• Supporation of local lymph nodes
• 2^o Pneumonia
• Hematogenous Spread to other organs resulting in:

     Pericarditis

     Osteomyelitis

     Meningitis

     Sepsis

     Hepatitis/Jaunidce

     Splenic Rupture

     Encephalitis

     Peritonitis

• Renal Failure
• Rhabomyolisis (typhoidal form)
• ARDS (penumonic form)
• Lung Abscess (pneumonic form)
• Fibrosis/Calcification of affected lung areas (pneumonic form)
• Pleuritis (pneumonic form)

With all forms of Tularmemia illness MAY result in such debilitating conditions (more so when other systems are     involved), that recovery can take several months.

   

Medical Management (current best evidence) 

Antimicrobials are currently the best treatment option for Tularemia infections.After beginning treatment one should expect to see an improvement in symptoms and fever within 24-48 hours.

• Aminoglycosides
• Streptomyocin 10-14 days (1st choice)
• May also be treated with gentamicin or tetracycline for 14+ days

       Tetracycline should not be used as a treatment in those whose permanent teeth have not came in.

• Quinolones
• Contraindicated in those < 18 years of age
• "well tolerated, achieve adequate blood levels...and have excellent intracellular penetration"

A review of 10 documented treatment cases in the United States found that those treated with Aminoglycosides have a 6-12% relapse rate of infection, while those treated with Quinolones had a 0% relapse rate.

Physical Therapy Management (current best evidence)

Currently did not come across any management in regards to physical therapy.

Alternative/Holistic Management (current best evidence)

The only reported treatments for Tularemia in the literature was through antibiotics. (See above section: Medications)

Differential Diagnosis

Glandular

• Bubonic Plague

          Systemic toxicity

• Cat-Scratch Disease

          History of cat scratch

          Takes weeks to develop

• Myobacterial Infection

          Lymph Nodes painless/non-tender

• Sporotrichosis

          No systemic symptoms, lymph nodes painless, history of contact w/ soil/plants, lesions along lymphatic chains 

• Streptococcal
• Lymphogranuloma Venereum

        Adenitis in genital lymph chains only

• Primary Genital Herpes

         Adenitis in genital lymph chains only

• Secondary Syphilis

         Enlarged lymph nodes in inguinal region only

Ulceroglandular

• Anthrax

    Painless ulcer --> black eschar; non-pitting edema around lesion

• Orf

    Pustule that progresses to weeping nodule

• Pasteurella infections

    History of dog/cat bite or licking of open wound

• Primary Syphillis

    Painless ulcer at genital site

• Ricketsialpox

    Painless papule --> black eschar; maculopapular rash in 2-3 days

• Scrub Typhus

    Maculopapular rash; Infection from chigger bites

• Staphylococcal/Stretococcal Cellulitis

    History of trauma or pre-existing lesion

Pneumonic

• Community Acquired Pneumonia

Won't cure with conventional antibitotic therapy

• Inhalation of Anthrax

Often fulminant

• Pneumonic Plague

Consolidation on Chest X-ray

Often Fulminant

• Q Fever

• Tuberculosis

More common in elderly and those living in close living quarters (shelters,jails,schools etc...)

• Viral Pneumonia

Recent cruise or trip to tropics

Exposure to feces/urine of mice

• Respiratory Syncytial Virus

• Cytomegalovirus

Case Reports/ Case Studies

Isolation of Francisella tularensis from blood.

Tularemia: Emergency department presentation of an infrequently recognized disease.

Treatment of tularemia with fluoroquinolones: two cases and review.

Resources

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Recent Related Research (from Pubmed)

see tutorial on Adding PubMed Feed

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References

see adding references tutorial.