Friday, September 29, 2023


Practice Essentials

Tularemia is an acute, febrile, granulomatous, infectious zoonosis caused by Francisella tularensis, an aerobic, gram-negative, pleomorphic bacillus. F tularensis is one of the most infectious bacterial species known. See the image below.

Eschar on thumb and under thumbnail at the site of

Eschar on thumb and under thumbnail at the site of a rabbit bite in a patient with tularemia.

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Signs and symptoms

The following are common findings in the various clinical forms of tularemia:

Abrupt onset of fever and chills – These symptoms typically last for several days, remit for a brief interval, and then recur

Pulse-temperature disassociation



Malaise and fatigue or prostration





Abdominal pain

Secondary pneumonitis – May occur in 45-83% of patients with the typhoidal form of tularemia

As many as 20% of patients with tularemia have a rash, which may begin as blotchy, macular, or maculopapular and progress to pustular. Erythema nodosum and erythema multiforme are rare.

More specific signs and symptoms are as follows:

Ulceroglandular tularemia – Includes painful regional lymphadenopathy and an ulcerated skin lesion

Glandular tularemia – Tender lymphadenopathy without evidence of local cutaneous lesions

Oculoglandular tularemia – Unilateral conjunctivitis, corneal ulceration, lymphadenopathy, photophobia, lacrimation, lid edema, vision loss (rare)

Oropharyngeal tularemia – Stomatitis and exudative pharyngitis or tonsillitis; abdominal pain, nausea, and vomiting; cervical lymphadenopathy; diarrhea; gastrointestinal bleeding

Intestinal tularemia – Abdominal pain, vomiting, and diarrhea

Pneumonic tularemia – Dry cough, dyspnea, and pleuritic-type chest pain

Typhoidal tularemia – Fever, chills, myalgias, malaise, and weight loss



The diagnosis of tularemia is usually based on serology results. Tests vary from antibody detection (using latex agglutination or enzyme-linked immunosorbent assay [ELISA] testing) to the examination of a range of polymerase chain reaction (PCR) assay products.

An agglutination titer greater than 1:160 is considered presumptively positive, and treatment may be started if this result is obtained. A second titer, demonstrating a 4-fold increase after 2 weeks, confirms the diagnosis.

Indirect fluorescent antibody testing

Indirect fluorescent antibody testing of suppurative material is rapid and specific. Microscopic examination of tissue and smear specimens is possible using fluorescently labeled antibodies at reference laboratories, possibly providing rapid confirmation of disease.

Histologic studies

Early tularemic lesions may demonstrate areas of focal necrosis surrounded by neutrophils and macrophages. Later, the necrotic areas become surrounded by epithelioid cells and lymphocytes. Caseating granulomata with or without multinucleated giant cells develops in some lesions.

Bacterial culturing

Although F tularensis has been cultured from sputum, pleural fluid, wounds, blood, lymph node biopsy samples, and gastric washings, the yield is extremely low and culturing poses a danger to laboratory personnel.


Chest radiography – To evaluate for pneumonia; this is indicated in any patient in whom the diagnosis of tularemia is suspected

Ultrasonography – To examine lymph nodes for findings suggestive of infection; however, these findings lack specificity


Medical care in tularemia is directed primarily toward antibiotic eradication of F tularensis, with streptomycin being the drug of choice (DOC) for this treatment. Research increasingly supports the use of fluoroquinolones to treat the disease, but clinical experience and in vitro data regarding their efficacy are limited.

Symptomatic and supportive care is applied for accompanying conditions (eg, osteomyelitis, pericarditis, peritonitis) in patients with tularemia, as clinically indicated.


No tularemia vaccine is currently available. A vaccine based on a live strain of the bacterium was previously available but is no longer produced because of concerns about unknown attenuation, safety, and production.


Avoid tick-infested areas

Wear trousers and long-sleeved shirts to avoid tick bites

Use tick repellants

Frequently inspect the body and clothing for evidence of ticks

Avoid exposure to dead or wild mammals and wear gloves if such exposure is necessary; hands should be thoroughly washed afterwards

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