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

• Chills • Prostration • Conjunctivitis • Diaphoresis • Axillary adenopathy • Cough • Hemoptysis

• Headache • Myalgias • Cutaneous ulcers • Weight loss • Epitrochlear adenopathy • Pleuritic chest pain, retrosternal pain

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

• Pericarditis
• Osteomyelitis
• Meningitis
• Pneumonia

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)

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

add appropriate resources here

Recent Related Research (from Pubmed)

see tutorial on Adding PubMed Feed

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References

see adding references tutorial.