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Key Features

Essentials of Diagnosis

  • A cutaneous or mucous membrane lesion at the site of inoculation and regional lymph node enlargement

  • Sudden onset of fever, chills, and prostration

  • History of contact with infected animals, principally wild rabbits, or history of tick exposure

  • Positive culture or immunofluorest staining of samples from mucocutaneous ulcer or regional lymph nodes

  • High serum antibody titer

General Considerations

  • Caused by Francisella tularensis

  • Ticks are the most important vector of tularemia and rabbits are the classic vector

  • Occasionally infection is acquired from infected domestic dogs or cats; by contamination of the skin or mucous membranes with infected blood or tissues; by inhalation of infected material; by bites of fleas or deer flies that have been in contact with infected animals; or by ingestion of contaminated meat or water

  • Incubation period is short, usually 3–7 days, but may vary from 2 to 25 days

Clinical Findings

Symptoms and Signs

  • Several clinical types of tularemia occur in children

  • Ulceroglandular form responsible for 60% of infections

    • Starts as a relatively nonpainful, reddened papule that may be pruritic and quickly ulcerates

    • Regional lymph nodes become large and tender

    • Fluctuance quickly follows

    • There may be marked systemic symptoms, including high fever, chills, weakness, and vomiting

    • Pneumonitis occasionally accompanies the ulceroglandular form or may be seen as the sole manifestation of infection (pneumonic form)

    • Detectable skin lesion may be absent, and localized lymphoid enlargement may exist alone (glandular form)

  • Oculoglandular and oropharyngeal forms also occur

    • Latter is characterized by tonsillitis, often with membrane formation, cervical adenopathy, and high fever

    • In the absence of a primary ulcer or localized lymphadenitis, a prolonged febrile disease reminiscent of typhoid fever can occur (typhoidal form)

  • Splenomegaly is common in all forms

Differential Diagnosis

  • Ulceroglandular type resembles pyoderma caused by staphylococci or streptococci, plague, anthrax, and cat-scratch fever

  • Oropharyngeal type must be distinguished from streptococcal or diphtheritic pharyngitis, mononucleosis, herpangina, or other viral pharyngitides

  • Typhoidal form may mimic typhoid, brucellosis, miliary tuberculosis, Rocky Mountain spotted fever, and mononucleosis

  • Pneumonic tularemia resembles atypical or mycotic pneumonitis


  • F tularensis can be recovered from ulcers, regional lymph nodes, blood, and sputum of patients with the pneumonic form

  • Immunofluorescent staining of biopsy material or aspirates of involved lymph nodes is diagnostic, although it is not widely available

  • WBC count is not remarkable

  • Diagnosis is typically confirmed by demonstration of a fourfold antibody titer rise between acute and convalescent serum samples


  • Antipyretics and analgesics may be given as necessary

  • Skin lesions are best left open

  • Glandular lesions occasionally require incision and drainage

  • Historically, streptomycin was the drug of choice

  • However, gentamicin is efficacious, more available, and familiar to clinicians; a 10-day course is ...

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