eMedicine Specialties > Infectious Diseases > Lower Respiratory Tract Infections

Tularemia: Differential Diagnoses & Workup

Author: Kerry O Cleveland, MD, Associate Professor of Medicine, University of Tennessee College of Medicine; Consulting Staff, Department of Internal Medicine, Division of Infectious Diseases, Methodist Healthcare of Memphis
Coauthor(s): Michael Gelfand, MD, FACP, Chief, Professor, Department of Internal Medicine, Division of Infectious Diseases, Methodist Healthcare of Memphis, University of Tennessee; Gregory J Raugi, MD, PhD, Professor, Department of Internal Medicine, Division of Dermatology, University of Washington at Seattle; Chief, Dermatology Section, Primary and Specialty Care Service, Veterans Administration Medical Center of Seattle
Contributor Information and Disclosures

Updated: Feb 4, 2009

Differential Diagnoses

Psittacosis
Q Fever

Other Problems to Be Considered

CBRNE - Plague
Diphtheria
Tick-borne Diseases, Colorado
Mycotic infections

Workup

Laboratory Studies

  • Routine laboratory testing is generally not helpful in tularemia, except to aid in excluding other diseases from the differential diagnoses.
  • Hematologic values are usually within the reference range. The WBC count may be slightly elevated. Occasionally, the WBC differential demonstrates lymphocytosis.
  • In 20-30% of patients with tularemia, urinalysis reveals sterile pyuria.
  • Liver function is usually normal. An elevated creatine phosphokinase (CPK) level may be associated with rhabdomyolysis and is a poor prognostic sign. High CPK values are more common in the typhoidal form of tularemia.
  • Examination of spinal fluid may demonstrate a slightly elevated protein value or a few WBCs; however, this is nonspecific.
  • Routine blood culture results are usually negative for tularemia. Successful cultivation requires media that contains cysteine for growth. Cultivation in the laboratory poses a hazard for workers; thus, laboratory personnel should always be advised if tularemia is suspected so that they may take appropriate precautions.
  • A Gram stain of sputum from a patient with pneumonic tularemia usually does not demonstrate F tularensis.

Imaging Studies

  • Obtain chest radiography to evaluate for pneumonia. As many as 30% of patients with tularemic pneumonia have no physical findings or respiratory tract symptoms.

Other Tests

  • The diagnosis of tularemia is usually based on serology results. Tularemia tube agglutination testing is the most commonly used serological test.5
    • Diagnosis is confirmed by a 4-fold increase in titer.
    • An acute-phase titer of 1:160 is suggestive, but such titers seldom develop until 11-21 days after onset of illness.
    • Titers of 1:10-80 occur in 1% of the American population, especially those with long-term exposure to rabbits. A titer result may be positive in absence of clinical disease.
    • Tularemia serologic tests may cross-react with Salmonella, Brucella, Yersinia, and Legionella species.
  • Skin testing may reveal a cellular immune response and is both sensitive and specific; however, skin test antigens are not commercially available.
  • Lymph node biopsy is generally not needed for diagnosis.
  • Polymerase chain reaction on material from wounds is being studied in some centers and appears promising as a means of earlier and easier diagnosis.6 This diagnostic modality is also being evaluated for potential use on other body substances.

Histologic Findings

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 may develop in some lesions.

More on Tularemia

Overview: Tularemia
Differential Diagnoses & Workup: Tularemia
Treatment & Medication: Tularemia
Follow-up: Tularemia
Multimedia: Tularemia
References
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References

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  2. Francis E. A summary of present knowledge of Tularaemia. Medicine. 1928;7:411-32.

  3. van de Beek D, Steckelberg JM, Marshall WF, Kijpittayarit S, Wijdicks EF. Tularemia with brain abscesses. Neurology. Feb 13 2007;68(7):531. [Medline].

  4. Mitchell LA, Bradsher RW Jr, Paden TC, Malak SF, Warmack TS, Nazarian SM. Tularemia induced bilateral optic neuritis. J Ark Med Soc. Mar 2006;102(9):246-9. [Medline].

  5. Gelfand MS, Slade W, Abolnik IZ. Tularemia serology: Differentiating true-positive and false-positive titers. Inf Dis Clin Pract. 1992;1:105-8.

  6. Tärnvik A, Chu MC. New approaches to diagnosis and therapy of tularemia. Ann N Y Acad Sci. Apr 27 2007;[Medline].

  7. Cronquist SD. Tularemia: the disease and the weapon. Dermatol Clin. Jul 2004;22(3):313-20, vi-vii. [Medline].

  8. Gallagher-Smith M, Kim J, Al-Bawardy R, Josko D. Francisella tularensis: possible agent in bioterrorism. Clin Lab Sci. 2004;17(1):35-9. [Medline].

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  16. Farlow J, Wagner DM, Dukerich M, Stanley M, Chu M, Kubota K. Francisella tularensis in the United States. Emerg Infect Dis. Dec 2005;11(12):1835-41. [Medline].

  17. Gill MV, Cunha BA. Tularemia Pneumonia. Sem Respir Infect. 1997;13:61-67.

  18. Guffey MB, Dalzell A, Kelly DR, Cassady KA. Ulceroglandular tularemia in a nonendemic area. South Med J. Mar 2007;100(3):304-8. [Medline].

  19. Kandemir B, Erayman I, Bitirgen M, Aribas ET, Guler S. Tularemia presenting with tonsillopharyngitis and cervical lymphadenitis: report of two cases. Scand J Infect Dis. 2007;39(6-7):620-2. [Medline].

  20. Leblebicioglu H, Esen S, Turan D, Tanyeri Y, Karadenizli A, Ziyagil F, et al. Outbreak of tularemia: a case-control study and environmental investigation in Turkey. Int J Infect Dis. May 2008;12(3):265-9. [Medline].

  21. Markowitz LE, Hynes NA, de la Cruz P, et al. Tick-borne tularemia. An outbreak of lymphadenopathy in children. JAMA. Nov 22-29 1985;254(20):2922-5. [Medline].

  22. Matyas BT, Nieder HS, Telford SR 3rd. Pneumonic tularemia on Martha's Vineyard: clinical, epidemiologic, and ecological characteristics. Ann N Y Acad Sci. Jun 2007;1105:351-77. [Medline].

  23. Nigrovic LE, Wingerter SL. Tularemia. Infect Dis Clin North Am. Sep 2008;22(3):489-504. [Medline].

  24. Penn RL, Kinasewitz GT. Factors associated with a poor outcome in tularemia. Arch Intern Med. Feb 1987;147(2):265-8. [Medline].

  25. Sinclair JR, Newton A, Hinshaw K, Fraser G, Ross P, Chernak E, et al. Tularemia in a park, Philadelphia, Pennsylvania. Emerg Infect Dis. Sep 2008;14(9):1482-3. [Medline].

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Further Reading

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Keywords

tularemia, Francisella tularensis, F tularensis, glandular tularemia, ulceroglandular tularemia, oculoglandular tularemia, pulmonary tularemia, pulmonic tularemia, pneumonic tularemia, tularemia pneumonia, oropharyngeal tularemia, typhoidal tularemia, septicemic tularemia, rabbit fever, deer-fly fever, plaguelike disease of rodents, glandular-type of tick fever, wild hare disease, market men's disease, water-rat trapper's disease, tick-borne disease, adult respiratory distress syndrome, ARDS, bioterrorism, biological warfare

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Contributor Information and Disclosures

Author

Kerry O Cleveland, MD, Associate Professor of Medicine, University of Tennessee College of Medicine; Consulting Staff, Department of Internal Medicine, Division of Infectious Diseases, Methodist Healthcare of Memphis
Kerry O Cleveland, MD is a member of the following medical societies: American College of Physicians, American Medical Association, Infectious Diseases Society of America, and Society for Healthcare Epidemiology of America
Disclosure: Nothing to disclose.

Coauthor(s)

Michael Gelfand, MD, FACP, Chief, Professor, Department of Internal Medicine, Division of Infectious Diseases, Methodist Healthcare of Memphis, University of Tennessee
Michael Gelfand, MD, FACP is a member of the following medical societies: American College of Physicians, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, and Southern Medical Association
Disclosure: Nothing to disclose.

Gregory J Raugi, MD, PhD, Professor, Department of Internal Medicine, Division of Dermatology, University of Washington at Seattle; Chief, Dermatology Section, Primary and Specialty Care Service, Veterans Administration Medical Center of Seattle
Gregory J Raugi, MD, PhD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

Medical Editor

Mark R Wallace, MD, FACP, FIDSA, Clinical Professor of Medicine, Florida State University College of Medicine; Infectious Disease Fellowship Director, Orlando Regional Medical Center
Mark R Wallace, MD, FACP, FIDSA is a member of the following medical societies: American College of Physicians, American Medical Association, American Society of Tropical Medicine and Hygiene, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Richard B Brown, MD, FACP, Chief, Division of Infectious Diseases, Baystate Medical Center; Professor, Department of Internal Medicine, Tufts University School of Medicine
Richard B Brown, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Chest Physicians, American College of Physicians, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, and Massachusetts Medical Society
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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