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Tularemia

-rural disease
-uncommon zoonosis
-long treatment
-potential bioterrorist weapon

Etiology
Name Francisella tularensis
Type Facultative intracellular gram ve
Morphology - Coccobacilli
Lipid Envelope Yes
Environ. Resistance - Able to survive in
water, moist soil and decaying carcasses
Humans Incidental hosts
Pathogenicity factors
a. Resistance to phagocytosis
b. O-antigen presence
c. LPS
Strains Type A and Type B
Character Explanation
Type A
Virulence More virulent
Place
North America, Central Asia
Reservoir Lagomorphs (hares, rabbits)
Type B
Virulence Less Virulent
Place
Eurasia, North America
Reservoir Aquatic rodents (beavers)

Transmission:
a. Bites of infected ticks, others
b. Skin/mucosa (direct contact)
c. Ingestion contaminated
food/water
d. Aerosol inhalation
Seasonality summer (mosquitoes)
Reservoirs Domestic animals, birds,
fish, mammals, etc
Vectors ticks, deer flies, mosquitoes,
athropods
High risk groups hunters, hikers,
farmers, enzootic areas exposed people

Pathogenesis
Principal pathologic changes:
At initial site & regional lymph nodes
Organs involved:
Lungs, spleen, lymph nodes, liver, skin
Primary skin lesion
Inoculation Several Days Papule
Rapidly Vesicles Erosion Ulcers
Ulcer characteristics 2-3 cms diameter,
necrotic base, covered by thick scab
Affected lymph nodes Hemorrhagic
necrosis, may suppurate
Immune cell response:
Type cell mediated

Fundamental element Granulomas


Primary cell infected - Macrophages

Clinical
Incubation period 2-5 days
Onset Sudden
Death multiple organ failures
Clinical features of primary form
Form
Characteristics
45-85%
UlceroUlcers occur + painful
glandular
lymphadenitis
10-25%
Glandular
No cutaneous ulceration
<5%
OculoUlceration, papule on
glandular
conjunctiva
<5%
Typhoidal
Acute illness without
or Septic
localizing signs
<5%
Ingestion contam. material
Exudative meningitis
OroTender cervical
Pharyngeal
lymphadenopathy
Only 1 tonsilla involved
(white coated)
<5%
Common secondary
Pneumonic complication
Cough with minimal sputum
production

Symptoms:
a. Fever (38-40oC, any type)
b. Chills
c. Headache
d. Generalized body aches
e. Nausea
f. Weakness
g. Cough
h. Chest pain

Differentials

Symptoms complex
a. Primary effect
b. Infectious-toxic
c. Infectious allergic

Treatment

Special considerations:
a. If not treated, non-specific symptoms
persist for several weeks
b. Sweats & chills means continuing
illness
c. Any primary forms may be
complicated by bacteremia and secondary
sepsis

Diagnosis
a. Culture isolation
BCYE media (Buffered Charcoal
Yeast Extract)
b. Serology
IHA, Titers rise >1:160
c. Skin test
Tularin

a.
b.
c.
d.
e.
f.

Felinosis
Lymphogranulomatosis
Purulent lymphadenitis
Plague bubonic form
Pharyngeal diphtheria
Other tick-borne diseases (RMSF,
Q Fever, Lyme Disease)

General principles:
a. Usually use combination 2
antibiotics
b. Disintoxication therapy
c. Anti-allergic therapy
d. Surgery
Antibiotics:
a. Streptomycin
b. Gentamicin
c. Tetracycline
d. Doxycycline
e. Ciprofloxacin
Others chloramphenicol, rifampicin
NSAIDs

Websites
www.bt.cdc.gov/agent/tularemia/
www.emedicine.com/emerg/topic591
en.wikipedia.org/wiki/Tularemia

MCQ Extra Info


Other clinical forms generalized,
bubonic, abdominal
Bubonic tularemia wave like fever,
absent lymphangitis, legible circuits of
bubos
(? similar to ulcero-glandular ?)
Bubos characteristics moderate
tenderness during palpation, absence of
inflamed surrounding tissues, legible
circuits and motility
Oculobubonic tularemia papule
conjunctivitis, erosion-ulcer
conjunctivitis, blepharospasm
(similar to oculo-glandular)
Anginose bubonic tularemia necrotic
tonsillitis, submaxillary lymphadenitis,
one tonsil predominant involvement
(similar to oro-pharyngeal)
Pulmonary tularemia tracheobronchitis,
enlarged paratracheal and mediastinal
lymph nodes, pneumonia
2 variants bronchial, pneumonic
(similar to pneumonic)
Abdominal tularemia mesenterial
lymphadenitis, hepatolienal syndrome,
symptoms of intoxication