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Tularemia — Clinical Guidelines

Overview

Tularemia is a zoonotic disease caused by Francisella tularensis, presenting with various clinical forms including ulceroglandular, glandular, and oropharyngeal manifestations. It can be contracted through contact with infected animals, ingestion of contaminated food, or arthropod bites. 1 2 3 4 5 6 12 13 14

Diagnosis

Clinical Presentation: Common symptoms include sore throat (100%), fever (93%), myalgia (100%), lymphadenopathy (100%), pharyngeal hyperemia (85%), tonsillitis (74%), and occasionally rash (7%). 1

Laboratory Tests: Serological tests (agglutination, ELISA) and PCR are crucial for diagnosis. Cultures may be negative or delayed in showing results. 1 4 7 14

Imaging: CT scans may show lymphadenopathy and pharyngeal inflammation. 11

Histopathology: Not routinely required but can confirm diagnosis in atypical cases. 3

Management

Antibiotics: First-line treatment typically includes aminoglycosides (e.g., streptomycin) or tetracyclines (e.g., doxycycline). Alternative options include fluoroquinolones (e.g., ciprofloxacin) and gentamicin. 1 5 12

Duration: Treatment duration generally ranges from 10 to 14 days, depending on the severity and form of tularemia. 5

Supportive Care: Includes hydration, fever management, and symptomatic relief. 10

Special Populations

Pediatrics: Symptoms in children are similar to adults, but diagnosis may be delayed due to atypical presentations. 1

Elderly: No specific differences noted, but careful monitoring for complications is advised. 5

Comorbidities: No specific recommendations vary based on comorbidities; however, immunocompromised individuals may require closer monitoring and potentially longer treatment durations. 8

Key Recommendations

Early Diagnosis and Treatment: Prompt initiation of appropriate antibiotic therapy is crucial to prevent complications and reduce mortality. (Evidence: Strong 1 5)

Serological Testing: Utilize serological tests for definitive diagnosis, especially when clinical suspicion is high despite negative cultures. (Evidence: Moderate 4 7)

Consider Tularemia in Differential: Include tularemia in the differential diagnosis for patients presenting with tonsillopharyngitis and cervical lymphadenopathy, particularly if unresponsive to initial treatments. (Evidence: Moderate 14 12)

References

1 Kaya A, Deveci K, Uysal IO, Güven AS, Demir M, Uysal EB et al.. Tularemia in children: evaluation of clinical, laboratory and therapeutic features of 27 tularemia cases. The Turkish journal of pediatrics 2012. link 2 Djordjevic-Spasic M, Potkonjak A, Kostic V, Lako B, Spasic Z. Oropharyngeal tularemia in father and son after consumption of under-cooked rabbit meat. Scandinavian journal of infectious diseases 2011. link 3 Ugur KS, Ark N, Kilic S, Kurtaran H, Kosehan D, Gunduz M. Three cases of oropharyngeal tularemia in Turkey. Auris, nasus, larynx 2011. link 4 Dlugaiczyk J, Harrer T, Zwerina J, Traxdorf M, Schwarz S, Splettstoesser W et al.. Oropharyngeal tularemia--a differential diagnosis of tonsillopharyngitis and cervical lymphadenitis. Wiener klinische Wochenschrift 2010. link 5 Komitova R, Nenova R, Padeshki P, Ivanov I, Popov V, Petrov P. Tularemia in bulgaria 2003-2004. Journal of infection in developing countries 2010. link 6 Kandemir B, Erayman I, Bitirgen M, Aribas ET, Guler S. Tularemia presenting with tonsillopharyngitis and cervical lymphadenitis: report of two cases. Scandinavian journal of infectious diseases 2007. link 7 Jiang J, Parker CE, Fuller JR, Kawula TH, Borchers CH. An immunoaffinity tandem mass spectrometry (iMALDI) assay for detection of Francisella tularensis. Analytica chimica acta 2007. link 8 Haristoy X, Lozniewski A, Tram C, Simeon D, Bevanger L, Lion C. Francisella tularensis bacteremia. Journal of clinical microbiology 2003. link 9 Arikan OK, Koç C, Bozdoğan O. Tularemia presenting as tonsillopharyngitis and cervical lymphadenitis: a case report and review of the literature. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery 2003. link 10 Gustafson BW, DeBowes LJ. Tularemia in a dog. Journal of the American Animal Hospital Association 1996. link 11 Nordahl SH, Hoel T, Scheel O, Olofsson J. Tularemia: a differential diagnosis in oto-rhino-laryngology. The Journal of laryngology and otology 1993. link 12 Luotonen J, Syrjälä H, Jokinen K, Sutinen S, Salminen A. Tularemia in otolaryngologic practice. An analysis of 127 cases. Archives of otolaryngology--head & neck surgery 1986. link 13 Wills PI, Gedosh EA, Nichols DR. Head and neck manifestations of tularemia. The Laryngoscope 1982. link 14 Everett ED, Templer JW. Oropharyngeal tularemia. Archives of otolaryngology (Chicago, Ill. : 1960) 1980. link 15 Nutter JE. Antigens of Pasteurella tularensis: preparative procedures. Applied microbiology 1971. link 16 Green JH, Bolin RC, Carver RK, Gross H, Pigott N, Harrell WK. Preparation of agglutinating antisera and fluorescent-antibody conjugates against Pasteurella tularensis in equines. Applied microbiology 1970. link

Tularemia