Sections

Tularemia

DDx

Diagnostic Considerations

Failure to consider tularemia in the differential diagnoses may lead to death if the patient is not treated properly.

Ulceroglandular tularemia is more likely to be diagnosed correctly than the typhoidal form because of the typical presentation of the former.

The typhoidal form, which is more deadly, presents as a nonspecific febrile illness, with little to suggest tularemia in the absence of a carefully taken epidemiologic history. In patients with typhoidal tularemia, other potentially life-threatening infections should be considered and excluded or should be treated as appropriate. Supportive care with fluids and antipyretics may be indicated.

A Turkish study concluded that serologic tests should be used to differentiate between tuberculous cervical lymphadenitis (TCL) and oropharyngeal tularemia, both of which have similar clinical findings. In the study, Karabay et al obtained serum from 1170 persons who had been diagnosed with TCL and from 596 healthy controls. Examining titers of 1:80 or higher, the investigators found that serum from 79 (6.75%) of the patients diagnosed with TCL was positive for F tularensis antibodies, whereas serum from only two (0.34%) persons in the control group showed positive results.^[62]

Other conditions to consider in the differential diagnosis of tularemia include the following:

Mumps
Mycoplasma infections
Parainfluenza virus infections
Bacterial pericarditis
Viral pericarditis
Pharyngitis
Plague
Pneumonia
Rhabdomyolysis
Rickettsial infection
Rocky Mountain spotted fever
Salmonella infection
Sporotrichosis
Syphilis
Toxoplasmosis
Tuberculosis
Catscratch disease
Plague
Lymphogranuloma venereum
Brucellosis
Influenza
Leishmaniasis
Anthrax
Disseminated mycobacterial disease
Disseminated fungal disease
Rat-bite fever
Nontuberculous mycobacterial infections

Differential Diagnoses

Chlamydial Infections
Diphtheria
Endocarditis, Bacterial
Endocarditis, Fungal
Legionella Infection
Lyme Disease
Malaria
Mononucleosis and Epstein-Barr Virus Infection
Psittacosis (Parrot Fever)
Q Fever

Workup

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Media Gallery

Eschar on thumb and under thumbnail at the site of a rabbit bite in a patient with tularemia.
Axillary bubo in a patient with tularemia.
Ulceroglandular type of 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.

of 5

Author

Kerry O Cleveland, MD 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, Infectious Diseases Society of America, 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 Health Science Center College of Medicine

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, Southern Medical Association

Disclosure: Nothing to disclose.

Chief Editor

John L Brusch, MD, FACP Corresponding Faculty Member, Harvard Medical School

John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

Gregory J Raugi, MD, PhD Professor, Department of Internal Medicine, Division of Dermatology, University of Washington at Seattle School of Medicine; 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.

Acknowledgements

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.

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.

Jonathan A Edlow, MD Associate Professor of Medicine, Department of Emergency Medicine, Harvard Medical School; Vice Chairman, Department of Emergency Medicine, Beth Israel Deaconess Medical Center

Jonathan A Edlow, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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.

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.

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

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

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: Nothing to disclose.

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.

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.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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: Novartis Honoraria Speaking and teaching

Mark R Wallace, MD, FACP, FIDSA Clinical Professor of Medicine, Florida State University College of Medicine; Head of Infectious Disease Fellowship Program, 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.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Tularemia Differential Diagnoses

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