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Quick Facts about Tularemia

• Tularemia is a zoonosis caused by Francisella tularensis, a gram-negative coccobacillus
• • F. tularensis is found in widely diverse animal hosts and habitats throughout the world. It can be recovered from water, soil, and vegetation
  • Humans can be infected through the skin, mucous membranes, gastrointestinal tract, and lungs
• General symptoms
• • After an incubation period of 2 to 10 days, there is the abrupt onset of fever (38°C to 40°C), headache, chills, rigors, myalgias, coryza, and sore throat
  • Nearly half of patients demonstrate a pulse-temperature dissociation
  • A dry or slightly productive cough and substernal chest pain are common, even in the absence of pneumonia
  • Nausea, vomiting, and diarrhea can sometimes occur
• Seven forms of tularemia are recognized
• • Ulceroglandular
  • • Accounts for 60% to 80% of all naturally occurring cases
    • Typically results from handling an infected carcass or follows the bite of an infected arthropod or bite or scratch of another animal
    • With the onset of generalized symptoms, a papule appears at the inoculation site. It quickly becomes pustular, ulcerates, and may develop an eschar
    • Regional lymphadenopathy develops; it may suppurate and rupture
  • Oculoglandular
  • • Ulceration occurs on the conjunctiva, accompanied by chemosis, vasculitis, and regional lymphadenitis
  • Glandular
  • • Lymphadenopathy and generalized symptoms without an ulcer
  • Oropharyngeal
  • • Acquired by ingesting contaminated water, food, or occasionally by inhaling contaminated droplets
    • The patient may develop stomatitis, but more commonly develops exudative pharangitis or tonsillitis with ulceration
    • Cervical or retropharyngeal lymphadenopathy may occur
  • Tularemia pneumonia
  • • Can result from direct inhalation of contaminated aerosols (naturally occuring or deliberately disseminated, as in a bioterrorist attack) or be secondary to hematogenous spread from another site
    • One or more of the following is present: pharyngitis, bronchiolitis, pleuropneumonitis, hilar lymphadenitis
    • In the correct clinical setting, the presence of nodular infiltrates with a pleural effusion should suggest either tularemia or plague pneumonia
    • In a substantial number of patients, pulmonary signs may be minimal or absent, and generalized constitutional symptoms may predominate
  • Typhoidal tularemia
  • • A systemic illness in the absence of signs indicating either a site of inoculation or anatomic localization of infection
    • Gastrointestinal manifestations including abdominal pain and diarrhea, may be presenting symptoms
  • Tularemia sepsis
  • • Nonspecific findings of fever, abdominal pain, diarrhea, and vomiting are early symptoms
    • May progress to septic shock with complications of the systemic inflammatory response including disseminated intravascular coagulation, adult respiratory distress syndrome, and multiple organ failure
• Diagnosis
• • The disease may be suspected by the clustering of acute, severe respiratory illness in previously healthy persons
  • The disease may be suspected in individuals with a pneumonia and negative blood cultures, and who do not respond to beta-lactam antibiotics
  • F. tularensis may be identified by examination of secretions, exudates, or biopsy specimens using direct fluorescent antibody or immunohistochemical stains performed in designated laboratories
  • Routine cultures are rarely positive. Growth requires the addition of cysteine to the culture media
  • Antigen detection assays, polymerase chain reaction, enzyme-linked immunoassays, immunoblotting, and other specialized techniques can be performed in research or reference laboratories
• Treatment (based upon the interim recommendations of the Working Group on Civilian Biodefense, Johns Hopkins University Schools of Medicine)
• • Adults: preferred choices
  • • Streptomycin, 1 g IM BID
    • Gentamicin, 5 mg/kg IM or IV once daily
  • Adults: Alternative choices
  • • Doxycycline, 100 mg IV BID or 200 mg IV once daily
    • Ciprofloxacin, 400 mg IV BID
    • Chloramphenicol, 15 mg/kg IV QID
  • Children: Preferred choices
  • • Streptomycin, 15 mg/kg IM BID, maximum dose 2 g
    • Gentamicin, 2.5 mg/kg IM or IV TID
  • Children: Alternative choices
  • • Doxycycline: If > 45 kg, give adult dose. If < 45 kg, give 2.2 mg/kg IV BID (maximum dose 200 mg/day)
    • Ciprofloxacin, 15 mg/kg IV BID
    • Chloramphenicol, 25 mg/kg IV QID
  • Pregnant women: Preferred choice
  • • Gentamicin, 5 mg/kg IM or IV once daily
  • Pregnant women: Alternative choices
  • • Doxycycline, 100 mg IV BID
    • Ciprofloxacin, 400 mg IV BID
  • Relapses can occur with any antibiotic regimen but are most often associated with the use of tetracyclines or chloramphenicol
  • Treatment with streptomycin, gentamicin, or ciprofloxacin should be continued for 10 days; treatment with doxycycline or chloramphenicol should be continued for 14-21 days. Persons beginning treatment with intramuscular (IM) or intravenous (IV) doxycycline, ciprofloxacin, or chloramphenicol can switch to oral antibiotic administration when clinically indicated.
• Post-exposure prophylaxis for asymptomatic persons (during early incubation period)
• • Adults: oral doxycycline, 100 mg BID x 14 days
  • Children: if > 45 kg give adult oral doxycycline dosage. If < 45 kg, give
  • oral doxycycline, 2.2 mg/kg BID x 14 days
  • Pregnant women: oral doxycycline, 100 mg BID x 14 days or ciprofloxacin, 500 mg orally x 14 days
  • Treat as active infection as outlined above for any person who develops an unexplained fever or flu-like illness after known exposure
• Infection Control
• • Isolation is not necessary because there is no human-to-human transmission
  • Standard hospital precautions are recommended

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