Tularemia in Emergency Medicine Clinical Presentation

The general history for tularemia may include fever, chills, myalgias, and malaise. Occasionally, patients with tularemic meningitis, pericarditis, peritonitis, endocarditis, and osteomyelitis have symptoms that correspond to the organ system or systems involved. However, the usual manifestations correlate with the pathophysiological form outlined above.

Ulceroglandular forms

Patients have ulcers at the site of inoculation. Ulceroglandular tularemia on the face is shown below.

In rabbit-associated cases, ulcers usually are on the fingers or hands (shown in the image below).

In tick-associated cases, common sites include the groin, axillae, and trunk. Swollen regional glands reflect this same geographic pattern. Infected nodes are painful. An affected extremity is shown in the image below.

Glandular form

This form is distinguished from the ulceroglandular form by the absence of an ulcer.

The bacterium presumably gains entry via microscopic abrasions or potentially through intact skin.

Oculoglandular form

The patient has a painful, red eye, often with purulent exudate.

Swollen glands may occur in submandibular, preauricular, or cervical areas.

Oropharyngeal form

Produced from eating undercooked infected meat, this form is associated with a sore throat, abdominal pain, nausea, vomiting and diarrhea, and occasionally, GI bleeding.

Abdominal pain is caused by mesenteric adenopathy, and bleeding results from intestinal ulcerations.

Pneumonic form

Note: Considering tularemia in patients presenting with atypical pneumonia, especially with the epidemiologic profile as below, is important.

In this form, produced by inhalation of organisms or by hematogenous spread from ulceroglandular or typhoidal disease, patients have a dry cough, dyspnea, and pleuritic chest pain. Landscaping during the summer months, especially cutting grass with a power mower, which may aerosolize organisms, is another described risk.

Some patients with tularemic pneumonia have systemic symptoms without these respiratory complaints.

Typhoidal (septicemic) form

F tularensis bacteremia causes this form and produces fevers, chills, myalgias, malaise, and weight loss.

The absence of an ulcer or lymphadenopathy makes diagnosis difficult.

Physical findings in tularemia vary with the mode of presentation.

Findings common to most cases are fever, tender hepatosplenomegaly, and in about 20% of patients, a generalized maculopapular rash that occasionally becomes pustular.

In one series, erythema nodosum occurred in 4 of 88 cases.^[2]

The ulcer forms at the site of skin entry of the organism. The location varies with the vector. The lesion starts as a tender papule that evolves into an ulcer with sharply demarcated borders and exudate. The base evolves from yellow to black. Regional nodes are edematous and tender, can become fluctuant, and may drain spontaneously.

Ocular findings may include unilateral intensely injected conjunctiva with purulent exudate, ulcerations and nodules on the palpebral conjunctiva, preauricular and cervical adenopathy, and corneal ulceration.

Exudative and membranous pharyngitis with regional adenopathy may be observed with the oropharyngeal form.

In the pneumonia form, rales are sometimes heard, but normal findings at lung examination are not uncommon.

Physical findings associated with pericarditis, peritonitis, meningitis, and osteomyelitis can be observed.

Tularemia is caused by infection with the bacteria F tularensis. The 2 subspecies are A (tularensis) and B (holartica). In the western United States, type A infections may be less severe than type B infections.