Tularemia in Emergency Medicine Workup

  • Author: Kelly Maurelus, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Apr 19, 2011
 

Laboratory Studies

  • Results of standard blood tests are nondiagnostic.
  • WBC count usually is normal or elevated. No consistent abnormality is found in other components of the CBC count.
  • In one series, urinalysis revealed pyuria in nearly one quarter of the cases.[2]
  • Serum chemical analysis reveals elevation of at least 1 test of hepatic function in about 50% of patients. An elevated creatine kinase level is associated with rhabdomyolysis and is a poor prognostic sign.
  • Examination of the spinal fluid occasionally reveals an elevated protein level or a mild pleocytosis.
  • Findings with routine blood cultures usually are normal because the organism has unique growth requirements. Similarly, while the organism is present in the ulcers, it rarely grows in cultures.
  • The sputum of patients with tularemic pneumonia usually is white and does not reveal the pathogen.
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Imaging Studies

A chest radiograph is indicated, because roughly 30% of patients with tularemic pneumonia do not have respiratory symptoms. Overlap with other atypical pneumonias may exist.

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Other Tests

Definitive diagnosis usually is established with serologic testing. This is in part because the organism is often not present in large numbers in blood or sputum and, in any case, may be difficult to cultivate.

Notifying the hospital laboratory staff is important if tularemia is a serious differential diagnostic possibility, because the organism can grow on normal culture media and many episodes of laboratory technician disease have been reported. The organism should only be worked with in culture in a Biosafety Level 3 facility.

  • A 4-fold increase in the titer or a single titer of 1:160 or more is the common threshold, although this varies with the laboratory. The methods also vary from antibody detection by latex agglutination or enzyme-linked immunosorbent assay (ELISA) testing to a range of polymerase chain reaction (PCR) products that directly measure DNA from the organisms.[3]
  • One study revealed that no patient had a diagnostic titer before the 11th day of illness, but nearly all had one by day 16.[2] Therefore, in interpreting the result, one must factor in the timing of the serologic test.
  • Rabbit handlers and others may have an asymptomatic elevation in antitularemic antibody titers without disease; thus, the elevated titer in the absence of clinical tularemia does not establish a diagnosis.
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Contributor Information and Disclosures
Author

Kelly Maurelus, MD  Resident Physician, Department of Emergency Medicine, Kings County Hospital, State University of New York Downstate

Kelly Maurelus, MD, is a member of the following medical societies: American Medical Student Association/Foundation and Student National Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Richard H Sinert, DO  Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Dan Danzl, MD  Chair, Department of Emergency Medicine, Professor, University of Louisville Hospital

Dan Danzl, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Kentucky Medical Association, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Jon Mark Hirshon, MD, MPH  Associate Professor, Department of Emergency Medicine, University of Maryland School of Medicine

Jon Mark Hirshon, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Public Health Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD 

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

References

  1. CDC. Tularemia associated with a hamster bite--Colorado, 2004. MMWR Morb Mortal Wkly Rep. Jan 7 2005;53(51):1202-3. [Medline].

  2. Evans ME, Gregory DW, Schaffner W, McGee ZA. Tularemia: a 30-year experience with 88 cases. Medicine (Baltimore). Jul 1985;64(4):251-69. [Medline].

  3. Matero P, Hemmila H, Tomaso H, et al. Rapid field detection assays for Bacillus anthracis, Brucella spp., Francisella tularensis and Yersinia pestis. Clin Microbiol Infect. Jan 2011;17(1):34-43. [Medline].

  4. Perez-Castrillon JL, Bachiller-Luque P, Martin-Luquero M, et al. Tularemia epidemic in northwestern Spain: clinical description and therapeutic response. Clin Infect Dis. Aug 15 2001;33(4):573-6. [Medline].

  5. Alsan MM, Lin HW. Tularemia presenting as a cervical abscess. Otolaryngol Head Neck Surg. Aug 2010;143(2):311-2.e1. [Medline].

  6. Craven RB, Barnes AM. Plague and tularemia. Infect Dis Clin North Am. Mar 1991;5(1):165-75. [Medline].

  7. Dennis DT, Inglesby TV, Henderson DA, et al. Tularemia as a biological weapon: medical and public health management. JAMA. Jun 6 2001;285(21):2763-73. [Medline].

  8. Eliasson H, Broman T, Forsman M. Tularemia: current epidemiology and disease management. Infect Dis Clin North Am. Jun 2006;20(2):289-311, ix. [Medline].

  9. Ellis J, Oyston PC, Green M, Titball RW. Tularemia. Clin Microbiol Rev. Oct 2002;15(4):631-46. [Medline].

  10. Foley JE, Nieto NC. Tularemia. Vet Microbiol. Jan 27 2010;140(3-4):332-8. [Medline].

  11. Ikaheimo I, Syrjala H, Karhukorpi J, et al. In vitro antibiotic susceptibility of Francisella tularensis isolated from humans and animals. J Antimicrob Chemother. Aug 2000;46(2):287-90. [Medline].

  12. Jacoby I. Francisella tularensis (tularemia) attack. In: Ciottone G, ed. Disaster Medicine. Philadelphia, Pa: Mosby; 2006.

  13. Langley R, Campbell R. Tularemia in North Carolina, 1965-1990. N C Med J. Jul 1995;56(7):314-7. [Medline].

  14. Limaye AP, Hooper CJ. Treatment of tularemia with fluoroquinolones: two cases and review. Clin Infect Dis. Oct 1999;29(4):922-4. [Medline].

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

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

  17. Schmid GP, Kornblatt AN, Connors CA, et al. Clinically mild tularemia associated with tick-borne Francisella tularensis. J Infect Dis. Jul 1983;148(1):63-7. [Medline].

  18. Staples JE, Kubota KA, Chalcraft LG. Epidemiologic and molecular analysis of human tularemia, United States, 1964-2004. Emerg Infect Dis. Jul 2006;12(7):1113-8. [Medline].

  19. Thomas LD, Schaffner W. Tularemia pneumonia. Infect Dis Clin North Am. Mar 2010;24(1):43-55. [Medline].

 
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Ulceroglandular tularemia on the face. Courtesy of Dr Hon Pak.
Ulceroglandular tularemia on an extremity. Courtesy of Dr Hon Pak.
Ulceroglandular type of tularemia on the hand. Courtesy of Dr Hon Pak.
 
 
 
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