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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 (38C to 40C), 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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