Variation in Tularemia Clinical Manifestations—Arkansas, 2009–2013

Abstract

Background. Francisella tularensis, although naturally occurring in Arkansas, is also a Tier 1 select agent and potential bioterrorism threat. As such, tularemia is nationally notifiable and mandatorily reported to the Arkansas Department of Health. We examined demographic and clinical characteristics among reported cases and outcomes to improve understanding of the epidemiology of tularemia in Arkansas.Methods.Surveillance records on all tularemia cases investigated during 2009–2013 were reviewed.Results.The analytic dataset was assembled from 284 tularemia reports, yielding 138 probable and confirmed tularemia cases during 2009–2013. Arthropod bite was identified in 77% of cases. Of 7 recognized tularemia manifestations, the typhoidal form was reported in 47% of cases, approximately double the proportion of the more classic manifestation, lymphadenopathy. Overall, 41% of patients were hospitalized; 3% died. The typhoidal form appeared to be more severe, accounting for the majority of sepsis and meningitis cases, hospitalizations, and deaths. Among patients with available antibiotic data, 88% received doxycycline and 12% received gentamicin.Conclusions.Contrary to expectation, lymphadenopathy was not the most common manifestation observed in our registry. Instead, our patients were more likely to report only generalized typhoidal symptoms. Using lymphadenopathy as a primary symptom to initiate tularemia testing may be an insensitive diagnostic strategy and result in unrecognized cases. In endemic areas such as Arkansas, suspicion of tularemia should be high, especially during tick season. Outreach to clinicians describing the full range of presenting symptoms may help address misperceptions about tularemia.

An 8-Month-Old Girl with Prolonged Fever

“…For that reason, in the pediatric population, it is imperative to have a high suspicion of typhoidal tularemia infection in the setting of a febrile illness even without lymphadenopathy, especially during tick season in an endemic region. 1,2 Complications associated with tularemia include pneumonia, sepsis, and meningitis. 1 Interestingly, the CT scan of our patient's abdomen was significant for hematogenous spread with focal lesions involving the spleen.…”

“…1,2 Complications associated with tularemia include pneumonia, sepsis, and meningitis. 1 Interestingly, the CT scan of our patient's abdomen was significant for hematogenous spread with focal lesions involving the spleen. A PubMed (pubmed.gov) search of tularemia, human, and splenic lesion or splenic nodule found only one prior case.…”

“…Based on a retrospective study, arthropod bite was identified in 77% of cases, which was consistent with the mode of transmission in our current case. 1 Manifestation of tularemia infection varies. Of the seven forms of tularemia, the classic clinical presentation is ulcero-glandular.…”

“…Based on a retrospective study, arthropod bite was identified in 77% of cases, which was consistent with the mode of transmission in our current case. 1 …”

“…Of the seven forms of tularemia, the classic clinical presentation is ulcero-glandular. 1 Of note, each form is associated with symptoms consistent with an influenza-like illness, consisting of fevers, chills, headache, and myalgia. “Typhoidal” symptoms were reported in 47% of cases, double the proportion of the more classic manifestation of lymphadenopathy, which was contrary to the expectations.…”