Pediatric Tularemia Workup

  • Author: Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM; Chief Editor: Russell W Steele, MD   more...
 
Updated: Jul 23, 2010
 

Laboratory Studies

  • The diagnosis is based on clinical suspicion.
  • Standard laboratory results are nonspecific for tularemia.
  • Serum transaminase levels are mildly elevated in about one half of patients.
  • Urinalysis may show sterile pyuria in as many as one fourth of patients.
  • The CBC count may reveal an elevated WBC count in about one half of patients.
  • Mild thrombocytopenia may be present.
  • Hyponatremia is occasionally present.
  • Elevation of creatine kinase values may be observed and is associated with rhabdomyolysis.
  • Cerebrospinal fluid (CSF) may show hypoglycorrhachia, a mild elevation of protein concentration, and almost always demonstrates a mononuclear cell pleocytosis.
  • Although the organism has been cultured from sputum, pleural fluid, wounds, blood, lymph node biopsy samples, and gastric washings, the yield is extremely low and culture poses a danger to laboratory personnel. The plates must be sealed and handled by using a biosafety level-2 (BSL-2) facility, with further testing at BSL-3 facility after a presumptive identification of F tularensis.
    • Other potentially effective media include chocolate, buffered charcoal yeast extract, and Thayer Martin agar.
    • Specimens should be maintained for at least 10 days because the slow growth of the culture may require 48-72 hours to be identified.
    • Blood cultures have poor sensitivity, which is probably due to the specific medium (cysteine-glucose-blood agar) needed to culture this organism.
  • Serologic cross-reactivity is reported with Brucella species, Proteus Ox-19, Burkholderia species , Pseudomonas species, and Yersinia species. Studies reveal the following:
    • The diagnosis of tularemia is most often made with serologic testing. Antibodies may be measured by means of agglutination and enzyme-linked immunosorbent assay (ELISA).
    • An agglutination titer greater than 1:160 is considered presumptively positive, and treatment may be started if this result is obtained.
    • A second titer demonstrating a 4-fold increase in 2 weeks confirms the diagnosis. Note that although titers begin to rise within 7-10 days after exposure, early titers in the first 2 weeks of illness may be negative in the setting of infection. Detectable titers are identified in the second week of infection in more than 50% of cases.
    • Titers achieve maximum levels between 4-8 weeks and may remain elevated for years after infection, causing an uncertainty in individuals with a remote history of tularemia exposure.
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Imaging Studies

  • Chest radiography
    • Tularemia pneumonia may be present without respiratory symptoms.
    • Chest radiography is indicated in any patient in whom the diagnosis of tularemia is suspected.
    • Common findings in tularemia pneumonia include bilateral patchy infiltrates or lobar infiltrates (74%), cavitary lesions, which may be better visualized on chest CT, hilar lymphadenopathy (32%), or a pleural effusion (30%).
    • The triad of oval opacities, hilar lymphadenopathy, and pleural effusion is more likely with tularemia than with other tick-borne diseases.
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Other Tests

  • Indirect fluorescent antibody test of suppurative material is rapid and specific.
  • Microscopic examination of tissue and smear specimens is possible using fluorescent-labeled antibodies at reference laboratories, possibly providing rapid confirmation of disease.
  • Polymerase chain reaction (PCR), while very sensitive in artificial media, is less sensitive when applied to biological specimens. False negatives may occur. It has been used to detect F tularensis after initiation of antibiotic therapy. However, it is not yet available in most laboratories. PCR may provide rapid and specific confirmation, possibly including the disease phase. Real-time PCR assay for genetic typing of clinical and environmental isolates of F tularensis has been developed.[35, 36] A study on wound swabs from 40 patients with ulceroglandular tularemia found that PCR using 17-kDa primers was 75% sensitive and culture was 62% sensitive.[37]
  • Capture ELISA is an advancement based on monoclonal antibodies specific for lipopolysaccharide of the virulent forms of F tularensis. In animal studies, capture ELISA was more sensitive and specific than routine ELISA and in fact rivals PCR without the time and expense associated with PCR.
  • Other techniques available include antigen detection assays, immunoblotting, and pulsed-field gel electrophoresis. Unfortunately, availability of these techniques is largely limited to research or reference laboratories.
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Histologic Findings

  • Caseating granulomas may be found upon histologic examination of lymph nodes.
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Contributor Information and Disclosures
Author

Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM  Associate Professor, Education Officer, Department of Emergency Medicine, Hospital of the University of Pennsylvania; Director of Education and Research, PENN Travel Medicine

Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

William H Shoff, MD, DTM&H  Director, PENN Travel Medicine, Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania

William H Shoff, MD, DTM&H is a member of the following medical societies: American College of Physicians, American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Glaxo Smith Kline None None; Glaxo Smith Kline Honoraria Speaking and teaching

Specialty Editor Board

Robert W Tolan Jr, MD  Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine

Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility

Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Sanofi Pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

Leslie L Barton, MD  Professor Emerita of Pediatrics, University of Arizona College of Medicine

Leslie L Barton, MD is a member of the following medical societies: American Academy of Pediatrics, Association of Pediatric Program Directors, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Daniel Rauch, MD, FAAP  Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine

Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine

Disclosure: Baxter Honoraria Consulting

Chief Editor

Russell W Steele, MD  Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

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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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