Tularemia

No evidence exists for person-to-person transmission. Standard Precautions should be followed. Environmental surfaces should be decontaminated with soap and water and a hospital grade disinfectant.

 2-10 days

Most authorities still classify tularemia into six clinical forms that loosely correlate with the usual route of exposure and presenting complaints-ulceroglandular, glandular, oculoglandular, pharyngeal, typhoidal, and pneumonic. The size of the inoculum and host response undoubtedly plays some role in the clinical presentation. However some authorities prefer to lump the six categories into two basic groups: ulceroglandular, which accounts for about three fourths of the cases (and includes all presentations with skin or mucous membrane lesions or lymph nodes ≥ 1cm) and typhoidal, which accounts for the remaining quarter.

Most patients have fever; headache, chills, cough, chest pain, sore throat, vomiting, diarrhea, anorexia, and abdominal pain are also common. Stiff neck and back pain may occur. A rash may occur in up to one third of patients and can take almost any form-maculopapular, vesiculopapular, erythema nodosum, erythema multiforme, and urticaria.

Patients with oculoglandular tularemia present with painful, often purulent, conjunctivitis, which is associated with lymphadenopathy of the head and neck that may be preceded by photophobia and tearing.

Patients with pharyngeal tularemia, have severe sore throat unresponsive to penicillin; and those with classic typhoidal tularemia, have the nonspecific symptoms described above with no localizing symptoms. Skin lesions (ulceroglandular), may precede, follow, or occur concurrent to lymphadenopathy, and usually progress from a painful papule to a pustule that ulcerates with a raised border around a crater. Lymphadenopathy (glandular) may occur without skin lesions but with systemic symptoms. 

Pneumonic tularemia can be either primary or secondary; secondary pneumonia is particularly likely to accompany primary pharyngeal or classic typhoidal (ie, no obvious focus). Patients with pneumonic tularemia usually have a dry nonproductive cough, dyspnea, pleuritic chest pain, and fever. Physical examination may be nonspecific or reveal rales, a friction rub, or signs of consolidation or effusion.

Symptoms common to all forms include fever; headache, chills, cough, chest pain, sore throat, vomiting, diarrhea, anorexia, and abdominal pain, with stiff neck and back pain occurring less frequently. A rash occurs in about one third of patients varying from maculopapular, vesiculopapular, erythema nodosum, erythema multiforme, to urticaria.

Oculoglandular tularemia should be differentiated from bacterial and adenoviral eye infections. Because of the nonspecific symptoms associated with typhoidal tularemia, the differential diagnosis is broad and includes collagen-vascular diseases, neoplasms, and drug reactions as well as the infectious agents specifically associated with typhoid fever, tuberculosis, relapsing fever and more generally with abscesses, osteomyelitis, and endocarditis. 

Pneumonic tularemia should be differentiated from common causes of pneumonia such as infection with Legionella pneumophila, Mycoplasma pneumoniae, Chlamydia pneumoniae, and Streptococcus pneumoniae as well as rare causes of pneumonia such as Coxiella burnetii, Chlamydia psittaci, Mycobacterium tuberculosis, and the mycoses. Large numbers of patients presenting with similar systemic illnesses, in which a portion have a nonproductive pneumonia may be indicative of tularemia.

Diagnostic Tests: The organisms can be isolated or detected by PCR from blood, ulcers, conjunctival exudates, sputum, gastric washings, and pharyngeal exudates. Gram stain of smears or biopsies is rarely useful. Culture is hazardous to laboratory personnel and is technically difficult, particularly after institution of appropriate antibiotic therapy. Fourfold increase in tube agglutination or microagglutination titer is diagnostic of infection. Titers are usually negative during the first week of infection, positive in 50-70% of cases in the second week, and reach a maximum in 4-8 weeks. Cross-agglutination can occur with Brucella and Proteus species.

Specimen Submission: All specimens must be triple contained in an approved shipping container and have biohazard labels. Before transport is arranged, the receiving laboratory must be alerted prior to transport by calling (800) 252-8239 ("press 1"). Newly available diagnostic tests may be discussed at that time. Isolation is a significant laboratory hazard and must be performed in BSL-3 containment. Specimens must be accompanied by a Specimen Submission Form (G-1A) and submitted to the Texas Department of State Health Services Laboratory, 1100 West 49th Street, Austin, TX 78756. Tularemia should be prominently mentioned on the G-1A so that appropriate biosafety precautions will be taken in the laboratory.

Additional Tests: Routine examination of the sputum is not helpful, however a false-positive direct fluorescent antibody stain for Legionella on bronchoscopy specimens has been reported. Infected pleural fluid is exudative, negative on Gram stain, and usually contains more than 1000 leukocytes/mm³; cells are predominantly lymphocytes, but neutrophilic effusions may occur.

Secondary pleuropulmonary involvement is common in typhoidal cases, with pleural effusions or pulmonary infiltrates being present in up to 45% of patients. In patients with the pneumonic form of disease, 25-30% will have radiographic infiltrates without any clinical findings of pneumonia. White blood cell count and sedimentation rate may be normal or elevated. Thrombocytopenia, hyponatremia, elevated serum transaminase, increased creatine phosphokinase, myoglobinuria and sterile pyuria are sometimes present. Radiological evidence of pneumonia or mediastinal lymphadenopathy is usually evident. Acute radiographic changes may include subsegmental or lobar infiltrates, hilar adenopathy, pleural effusion, and apical or miliary infiltrates. Less common changes include ovoid densities, cavitation, and bronchopleural fistula.

Adults: Streptomycin 1 g IM 8-12 hours for 10 days, or gentamicin 5 mg/kg IM or IV for 10 days. Children: Streptomycin 15 mg/kg IM q 12 hours (should not exceed 2 g/d) for 10 days or gentamicin 2.5 mg/kg IM or IV q 8 hours for 10 days.

Prophylaxis: Adults: Doxycycline 100 mg q12h po for 14 days, or ciprofloxacin 500 mg q 12 hours po for 14 days. Children: Doxyclycline; if 45 ≥ kg, give 100 mg po q 12 hours; if < 45 kg, give 2.2 mg/kg po q 12 hours for 14 days or ciprofloxacin 15 mg/kg po q 12 hours for 14 days (not to exceed 1 g per day).

Reporting Requirements for Disease: Report any suspect cases of tularemia to your local health authority within one working day; or, call the Texas Department of State Health Services at 1-800-252-8239. Case clusters or multiple cases should be reported immediately.

Several Texas laws (Tex. Health & Safety Code, Chapters 81, 84 and 87) require specific information regarding notifiable conditions be provided to the Texas Department of State Health Services (DSHS). Health care providers, hospitals, laboratories, schools, and others are required to report patients who are suspected of having a notifiable condition (25 Tex. Admin. Code §97.2).

Report Tularemia within one working day to (800) 705-8868 or (800) 252-8239.

• Tularemia
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Tularemia is a bacterial disease of both animals and man. Although many wild and domestic animals have been infected, the rabbit is most often involved in disease outbreaks. Oklahoma is one of the states with relatively high rates of disease occurrence.

People who spend time out of doors are at risk of coming into contact with ticks, infected animals, or an area where an infected animal has died.

Many routes of human exposure to the tularemia bacteria are possible, although the most common route of transmission in Oklahoma is a bite from an infected tick. Other routes of transmission include contact of the skin or mucous membranes with blood or tissue of infected animals; or handling or eating insufficiently cooked rabbit meat. Less common means of spread are drinking contaminated water; inhaling dust from contaminated soil; or handling contaminated pelts or paws of animal

Following a bite from an infected tick or contamination of a skin wound, the symptoms of Tularemia would be fever, and an ulcerative skin sore, and painful swollen lymph glands. Ingestion of the organism may produce a throat infection, abdominal pain, diarrhea and vomiting. Inhalation of the organism may produce a fever alone or combined with a pneumonialike illness.

 Symptoms appear between 1 and 14 days, but usually after 3-5 days. If a person experiences a fever, or extreme soreness near the site of a tick bite within two weeks of a tick exposure, it is important to contact a physician as soon as possible and tell them about the tick bite.

Specific antibiotics are prescribed by a physician.

 Long term immunity will follow recovery from tularemia. However, reinfection has been reported.

Avoid tick exposure, tick bites, and tick infested areas. Minimize any contact pets might have with ticks as well. Rubber gloves should be worn when skinning or handling animals, especially rabbits. Wild rabbit and other game meat should be cooked thoroughly before eating.

 Any tick should be removed as soon as possible. The best way is to use tweezers to grab the tick as close to the skin as possible and pull it straight out. Do not squeeze the tick' s body when removing it. Do not handle ticks with bare hands. Wash hands thoroughly after removing a tick. Apply antiseptic to the bite to prevent secondary infections.

Tularemia can be transmitted (spread) naturally by eating or touching infected tissues, by breathing infected material, or by the bite of infected insects. Ticks are the most frequently reported sources of human infection in the US, followed by contact with infected rabbits.

 Animals that are naturally infected through the bite of a tick or by eating infected tissue may take as long as 10 days to become ill. Inhaling (breathing in) the bacteria will result in sudden fever, tiredness, loss of appetite, and a cough. Without treatment, death may occur within a few hours to a few days depending on how much was inhaled.

Diagnosis of this disease is generally very difficult because of unclear signs. Laboratory testing is available, but it is difficult to perform.

 Antibiotics usually can reduce the severity of the illness.

There is no vaccine available for animals. There is an investigational new drug for humans.

Yes. Spread of the disease is usually by the bite of insects (such as ticks) or by handling or eating an animal that died of tularemia. For example, hunters can be exposed while handling recently killed game, such as rabbits.

There are no special burial or disposal requirements.

Control ticks and other parasites to prevent spread of the disease to other animals and humans. Infected animals do not have to be isolated (separated), but all people handling them should wear gloves. Disinfect areas in contact with the infected animals with a mixture of one part household bleach (0.5% hypochlorite) in nine parts water. Apply to all surfaces and wash off with water after waiting at least 30 minutes.