Tularemia: Difference between revisions
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*Caused by the intracellular gram negative bacteria Francisella tularensis | *Caused by the intracellular gram negative bacteria Francisella tularensis | ||
*Primarily spread through tick and deer fly bites | *Primarily spread through tick and deer fly bites | ||
** Ticks that spread Tularemia include: | **Ticks that spread Tularemia include: | ||
#Dog tick (Dermacentor variabilis) | **#Dog tick (Dermacentor variabilis) | ||
#Wood tick(Dermacentor andersoni) | **#Wood tick (Dermacentor andersoni) | ||
#Lone star tick (Amblyomma americanum) | **#Lone star tick (Amblyomma americanum) | ||
* Also spread through contact with infected animals, ingestion of contaminated water, inhalation of aerosolized material (ex. running over dead animal with lawn mower) | *Also spread through contact with infected animals (rabbits, rodents), ingestion of contaminated water, inhalation of aerosolized material (ex. running over dead animal with lawn mower) | ||
===Potential [[Bioterrorism]] Threat=== | |||
*Listed by CDC as potential [[bioterrorism]] threat as the bacterium can be aerosolized, is highly infective, and highly incapacitating. | |||
==Clinical Features== | ==Clinical Features== | ||
[[File:Tularemia lesion.jpg|thumb|A tularemia lesion on the back of the right hand.]] | |||
[[File:PMC3223485 eplasty11e47 fig4.png|thumb|Tularemia with cutaneous lesions on the dorsum of the right hand.]] | |||
*Features depend on site of infection | *Features depend on site of infection | ||
*All are associated with fevers | *All are associated with fevers | ||
*At risk patient groups include farmers, meat handlers, landscapers, veterinarians, hunters, sheep shearers and taxidermists. | |||
===Ulceroglandular=== | ===Ulceroglandular=== | ||
*'''Most common form''', represents about 75% of disease | *'''Most common form''', represents about 75% of disease | ||
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**Usually inguinal or axillary | **Usually inguinal or axillary | ||
**Cervical or occipital in children | **Cervical or occipital in children | ||
===Glandular=== | ===Glandular=== | ||
*Regional lymphadenopathy with no skin lesions or ulceration | *Regional lymphadenopathy with no skin lesions or ulceration | ||
*Most common presentation among children | *Most common presentation among children | ||
*Suppurated nodes may need drainage | *Suppurated nodes may need drainage | ||
===Oropharyngeal=== | ===Oropharyngeal=== | ||
*From ingesting contaminated material | *From ingesting contaminated material | ||
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**Sore throat, | **Sore throat, | ||
**Mouth ulcers | **Mouth ulcers | ||
** Exudative pharyngitis/tonsilitis | **Exudative pharyngitis/tonsilitis | ||
**Cervical lymphadenitis | **Cervical lymphadenitis | ||
===Pneumonic=== | ===Pneumonic=== | ||
*Associated with highest mortality rate | *Associated with highest mortality rate | ||
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***Exudative effusion with lymphocytic predominance | ***Exudative effusion with lymphocytic predominance | ||
*May also be secondary to hematologic dissemination from other source | *May also be secondary to hematologic dissemination from other source | ||
===Oculoglandular=== | ===Oculoglandular=== | ||
*Occurs with inocculation into eye (aerosols, rubbing with contaminated fingers, splash, etc.) | *Occurs with inocculation into eye (aerosols, rubbing with contaminated fingers, splash, etc.) | ||
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**May lead to corneal ulceration | **May lead to corneal ulceration | ||
*May have preauricular, cervical or submandibular lymphadenopathy | *May have preauricular, cervical or submandibular lymphadenopathy | ||
=== | ===Typhoidal=== | ||
*Tularemia that does not fit into any of the other groups | *Tularemia that does not fit into any of the other groups | ||
**May present as sepsis | **May present as sepsis | ||
**Often has associated GI symptoms | |||
**No skin lesions | |||
==Differential Diagnosis== | |||
{{Tick borne illnesses DDX}} | |||
{{Bioterrorism agents}} | |||
== | ==Evaluation== | ||
*Titers | *Titers | ||
*PCR | *PCR | ||
*Gram stain does not usually reveal any organisms | *Gram stain does not usually reveal any organisms | ||
== | ==Management== | ||
===[[Antibiotics]]=== | |||
{{Tularemia antibiotics}} | |||
==Disposition== | ==Disposition== | ||
*Admit severe disease | *Admit severe disease | ||
*Can selectively treat mild disease | *Can selectively treat mild disease | ||
==See Also== | ==See Also== | ||
*[[Tick borne illnesses]] | *[[Tick borne illnesses]] | ||
*[[ | *[[Bioterrorism]] | ||
== | ==External Links== | ||
*http://www.cdc.gov/tularemia/index.html | *http://www.cdc.gov/tularemia/index.html | ||
==References== | |||
<references/> | |||
[[Category:ID]] | [[Category:ID]] | ||
Latest revision as of 16:36, 7 September 2022
Background
- Caused by the intracellular gram negative bacteria Francisella tularensis
- Primarily spread through tick and deer fly bites
- Ticks that spread Tularemia include:
- Dog tick (Dermacentor variabilis)
- Wood tick (Dermacentor andersoni)
- Lone star tick (Amblyomma americanum)
- Ticks that spread Tularemia include:
- Also spread through contact with infected animals (rabbits, rodents), ingestion of contaminated water, inhalation of aerosolized material (ex. running over dead animal with lawn mower)
Potential Bioterrorism Threat
- Listed by CDC as potential bioterrorism threat as the bacterium can be aerosolized, is highly infective, and highly incapacitating.
Clinical Features
- Features depend on site of infection
- All are associated with fevers
- At risk patient groups include farmers, meat handlers, landscapers, veterinarians, hunters, sheep shearers and taxidermists.
Ulceroglandular
- Most common form, represents about 75% of disease
- Present with a single erythematous ulcerative lesion with a central eschar
- This represents direct inoculation from the insect bite or from handling infected animals
- Lymphadenopathy
- Usually inguinal or axillary
- Cervical or occipital in children
Glandular
- Regional lymphadenopathy with no skin lesions or ulceration
- Most common presentation among children
- Suppurated nodes may need drainage
Oropharyngeal
- From ingesting contaminated material
- May cause outbreaks when water supply is disrupted
- Symptoms include:
- Sore throat,
- Mouth ulcers
- Exudative pharyngitis/tonsilitis
- Cervical lymphadenitis
Pneumonic
- Associated with highest mortality rate
- Results from direct inhalation of the bacterium into the lungs
- Farmers and herders at higher risk
- Acute infection associated with non-specific flu-like symptoms
- Progresses to more severe pneumonic signs
- Nodular infiltrates with pleural effusion on chest xray
- Exudative effusion with lymphocytic predominance
- Nodular infiltrates with pleural effusion on chest xray
- May also be secondary to hematologic dissemination from other source
Oculoglandular
- Occurs with inocculation into eye (aerosols, rubbing with contaminated fingers, splash, etc.)
- Pain, photophobia, tearing
- May have small ulcers of the conjunctiva or periorbital erythema
- May lead to corneal ulceration
- May have preauricular, cervical or submandibular lymphadenopathy
Typhoidal
- Tularemia that does not fit into any of the other groups
- May present as sepsis
- Often has associated GI symptoms
- No skin lesions
Differential Diagnosis
Tick Borne Illnesses
- Babesiosis
- Colorado tick fever
- Ehrlichiosis
- Heartland virus
- Lyme
- Murine typhus
- Rocky mountain spotted fever
- Southern tick-associated rash illness (STARI)
- Tick paralysis
- Tularemia
Bioterrorism Agents[1]
Category A
Category B
- Ricin
- Brucellosis
- Epsilon toxin
- Psittacosis
- Q Fever
- Staph enterotoxin B
- Typhus
- Glanders
- Melioidosis
- Food safety threats
- Water safety threats
- Viral encephalitis
Category C
- Influenza
- Yellow fever
- Tickborne hemorrhagic fever
- Tickborne encephalitis
Evaluation
- Titers
- PCR
- Gram stain does not usually reveal any organisms
Management
Antibiotics
Postexposure Prophylaxis
- Doxycycline 100mg PO q12hrs x 14 days OR
- Ciprofloxacin 500mg PO q12hrs q12hrs x 10 days
Active Disease
- Streptomycin 1g (15mg/kg) IM q12hrs daily x 10 days (First line) OR
- Gentamicin 5mg/kg/day IV/IM once daily x 10 days OR
- Ciprofloxacin 400mg (15mg/kg) q12hrs daily x 10 days OR
- Doxycycline 100mg (2.2mg/kg) IV q12hrs daily x 14 days OR
- Chloramphenicol 15mg/kg IV q6hrs daily x 14 days
Disposition
- Admit severe disease
- Can selectively treat mild disease