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Cash-Goldwasser S, Beeson A, Marzec N, Ho DY, Hogan CA, Budvytiene I, Banaei N, Born DE, Gephart MH, Patel J, Dietrich EA, Nelson CA. Neuroinvasive Francisella tularensis Infection: Report of 2 Cases and Review of the Literature. Clin Infect Dis 2024; 78:S55-S63. [PMID: 38294117 DOI: 10.1093/cid/ciad719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND Neuroinvasive infection with Francisella tularensis, the causative agent of tularemia, is rare. Establishing clinical suspicion is challenging if risk factors or clinical features classically associated with tularemia are absent. Tularemia is treatable with antibiotics; however, there are limited data to inform management of potentially fatal neuroinvasive infection. METHODS We collected epidemiologic and clinical data on 2 recent US cases of neuroinvasive F. tularensis infection, and performed a literature review of cases of neuroinvasive F. tularensis infection published after 1950. RESULTS One patient presented with focal neurologic deficits and brain lesions; broad-range molecular testing on resected brain tissue detected F. tularensis. The other patient presented with meningeal signs; tularemia was suspected based on animal exposure, and F. tularensis grew in cerebrospinal fluid (CSF) culture. Both patients received combination antibiotic therapy and recovered from infection. Among 16 published cases, tularemia was clinically suspected in 4 cases. CSF often displayed lymphocytic pleocytosis. Among cases with available data, CSF culture was positive in 13 of 16 cases, and F. tularensis antibodies were detected in 11 of 11 cases. Treatment typically included an aminoglycoside combined with either a tetracycline or a fluoroquinolone. Outcomes were generally favorable. CONCLUSIONS Clinicians should consider neuroinvasive F. tularensis infection in patients with meningitis and signs suggestive of tularemia or compatible exposures, lymphocyte-predominant CSF, unrevealing standard microbiologic workup, or lack of response to empiric bacterial meningitis treatment. Molecular testing, culture, and serologic testing can reveal the diagnosis. Favorable outcomes can be achieved with directed antibiotic treatment.
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Affiliation(s)
- Shama Cash-Goldwasser
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Amy Beeson
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Division of Vector-Borne Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado, USA
| | - Natalie Marzec
- Colorado Department of Public Health and Environment, Denver, Colorado, USA
| | - Dora Y Ho
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Catherine A Hogan
- Clinical Microbiology Laboratory, Stanford University Medical Center, Stanford, California, USA
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
| | - Indre Budvytiene
- Clinical Microbiology Laboratory, Stanford University Medical Center, Stanford, California, USA
| | - Niaz Banaei
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Clinical Microbiology Laboratory, Stanford University Medical Center, Stanford, California, USA
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
| | - Donald E Born
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
| | - Melanie H Gephart
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | | | - Elizabeth A Dietrich
- Division of Vector-Borne Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado, USA
| | - Christina A Nelson
- Division of Vector-Borne Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado, USA
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Maurin M, Pondérand L, Hennebique A, Pelloux I, Boisset S, Caspar Y. Tularemia treatment: experimental and clinical data. Front Microbiol 2024; 14:1348323. [PMID: 38298538 PMCID: PMC10827922 DOI: 10.3389/fmicb.2023.1348323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 12/31/2023] [Indexed: 02/02/2024] Open
Abstract
Tularemia is a zoonosis caused by the Gram negative, facultative intracellular bacterium Francisella tularensis. This disease has multiple clinical presentations according to the route of infection, the virulence of the infecting bacterial strain, and the underlying medical condition of infected persons. Systemic infections (e.g., pneumonic and typhoidal form) and complications are rare but may be life threatening. Most people suffer from local infection (e.g., skin ulcer, conjunctivitis, or pharyngitis) with regional lymphadenopathy, which evolve to suppuration in about 30% of patients and a chronic course of infection. Current treatment recommendations have been established to manage acute infections in the context of a biological threat and do not consider the great variability of clinical situations. This review summarizes literature data on antibiotic efficacy against F. tularensis in vitro, in animal models, and in humans. Empirical treatment with beta-lactams, most macrolides, or anti-tuberculosis agents is usually ineffective. The aminoglycosides gentamicin and streptomycin remain the gold standard for severe infections, and the fluoroquinolones and doxycycline for infections of mild severity, although current data indicate the former are usually more effective. However, the antibiotic treatments reported in the literature are highly variable in their composition and duration depending on the clinical manifestations, the age and health status of the patient, the presence of complications, and the evolution of the disease. Many patients received several antibiotics in combination or successively. Whatever the antibiotic treatment administered, variable but high rates of treatment failures and relapses are still observed, especially in patients treated more then 2-3 weeks after disease onset. In these patients, surgical treatment is often necessary for cure, including drainage or removal of suppurative lymph nodes or other infectious foci. It is currently difficult to establish therapeutic recommendations, particularly due to lack of comparative randomized studies. However, we have attempted to summarize current knowledge through proposals for improving tularemia treatment which will have to be discussed by a group of experts. A major factor in improving the prognosis of patients with tularemia is the early administration of appropriate treatment, which requires better medical knowledge and diagnostic strategy of this disease.
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Affiliation(s)
- Max Maurin
- Centre National de Référence Francisella tularensis, CHU Grenoble Alpes, Grenoble, France
- Université Grenoble Alpes, Translational Innovation in Medicine and Complexity (TIMC), Centre National de la Recherche Scientifique (CNRS), Grenoble, France
| | - Léa Pondérand
- Centre National de Référence Francisella tularensis, CHU Grenoble Alpes, Grenoble, France
- Université Grenoble Alpes, Commissariat à l’énergie atomique (CEA), CNRS, Institut de Biologie Structurale (IBS), Grenoble, France
| | - Aurélie Hennebique
- Centre National de Référence Francisella tularensis, CHU Grenoble Alpes, Grenoble, France
- Université Grenoble Alpes, Translational Innovation in Medicine and Complexity (TIMC), Centre National de la Recherche Scientifique (CNRS), Grenoble, France
| | - Isabelle Pelloux
- Centre National de Référence Francisella tularensis, CHU Grenoble Alpes, Grenoble, France
| | - Sandrine Boisset
- Centre National de Référence Francisella tularensis, CHU Grenoble Alpes, Grenoble, France
- Université Grenoble Alpes, Commissariat à l’énergie atomique (CEA), CNRS, Institut de Biologie Structurale (IBS), Grenoble, France
| | - Yvan Caspar
- Centre National de Référence Francisella tularensis, CHU Grenoble Alpes, Grenoble, France
- Université Grenoble Alpes, Commissariat à l’énergie atomique (CEA), CNRS, Institut de Biologie Structurale (IBS), Grenoble, France
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Mäki-Koivisto V, Korkala M, Simola L, Suutari-Kontio S, Koivunen S, Puhto T, Junttila IS. Positive Francisella tularensis meningitis outcome despite delayed identification: a case report. Ann Clin Microbiol Antimicrob 2023; 22:92. [PMID: 37875923 PMCID: PMC10598999 DOI: 10.1186/s12941-023-00642-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 10/04/2023] [Indexed: 10/26/2023] Open
Abstract
Francisella tularensis is a Gram-negative bacteria, that may cause a zoonotic disease, tularemia. Here, we describe a patient case, where a previously healthy young woman in Northern Finland contacted health care because of fever and headache. Due to the symptoms and lack of further diagnostic tools in primary health care, she was transferred to University Hospital (UH) where ampicillin and ceftriaxone was given empirically. A cerebrospinal fluid sample (CSF) was drawn showing small Gram-negative rods that grew on chocolate agar after 2 days of incubation. Matrix-assisted laser-desorption-ionization time of-flight (Maldi-tof) did not provide identification, but the bacteria was interpreted as sensitive to ciprofloxacin and the treatment was changed to ciprofloxacin. During the time the patient was infected, there were several positive tularemia samples found in the area. Therefore, an in house tularemia nucleic acid method (PCR) was used on the bacterial culture. Additionally, 16S rDNA sequencing was performed and these methods identified the bacteria as F. tularensis. Fortunately, the patient recovered completely with ciprofloxacin and was discharged without any complications. Our case underlines the need to understand the limits of specific diagnostic methods, such as Maldi-tof, used in clinical laboratory settings. It also highlights the need of both clinicians and laboratory staff to be aware of the many clinical presentations of tularemia when working in an endemic area.
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Affiliation(s)
| | | | | | | | | | | | - Ilkka S Junttila
- NordLab, Oulu, Finland.
- University of Oulu, Oulu, Finland.
- Tampere University, Tampere, Finland.
- Fimlab Laboratories, Tampere, Finland.
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Ducatez N, Melboucy S, Bentayeb H, Dayen C, Suguenot R, Lecuyer E, Douadi Y. A case of Francisella tularensis meningitis in a 64-year-old man treated with quinolones. Infect Dis Now 2021; 52:107-109. [PMID: 34242839 DOI: 10.1016/j.idnow.2021.06.306] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 06/13/2021] [Accepted: 06/29/2021] [Indexed: 10/20/2022]
Abstract
We report a French case of tularemic meningitis - the second to be thoroughly described - and discuss the existing literature. The patient is a 64-year-old man with no medical history, who developed fever, cutaneous symptoms, and swollen lymph nodes within a week after a hunt. He was then diagnosed with meningitis caused by Francisella tularensis subsp. holarctica. Healing was quickly achieved ad integrum within 3 weeks with a course of ciprofloxacin. We discuss the existing literature about this specific issue, and try to shine a light on the superior efficacy and lesser toxicity of quinolones compared to the historical treatment.
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Affiliation(s)
- N Ducatez
- Service de pneumologie et pathologies infectieuses, centre hospitalier de Saint-Quentin, 1, avenue Michel de l'Hospital, 02100 Saint-Quentin, France.
| | - S Melboucy
- Service de médecine interne et polyvalente, centre hospitalier de Saint-Quentin, 1, avenue Michel de l'hospital, 02100, Saint-Quentin, France
| | - H Bentayeb
- Service de pneumologie et pathologies infectieuses, centre hospitalier de Saint-Quentin, 1, avenue Michel de l'Hospital, 02100 Saint-Quentin, France
| | - C Dayen
- Service de pneumologie et pathologies infectieuses, centre hospitalier de Saint-Quentin, 1, avenue Michel de l'Hospital, 02100 Saint-Quentin, France
| | - R Suguenot
- Service de pneumologie et pathologies infectieuses, centre hospitalier de Saint-Quentin, 1, avenue Michel de l'Hospital, 02100 Saint-Quentin, France
| | - E Lecuyer
- Service de pneumologie et pathologies infectieuses, centre hospitalier de Saint-Quentin, 1, avenue Michel de l'Hospital, 02100 Saint-Quentin, France
| | - Y Douadi
- Service de pneumologie et pathologies infectieuses, centre hospitalier de Saint-Quentin, 1, avenue Michel de l'Hospital, 02100 Saint-Quentin, France
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van Samkar A, Brouwer MC, van der Ende A, van de Beek D. Zoonotic bacterial meningitis in human adults. Neurology 2016; 87:1171-9. [PMID: 27534710 DOI: 10.1212/wnl.0000000000003101] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 06/01/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To describe the epidemiology, etiology, clinical characteristics, treatment, outcome, and prevention of zoonotic bacterial meningitis in human adults. METHODS We identified 16 zoonotic bacteria causing meningitis in adults. RESULTS Zoonotic bacterial meningitis is uncommon compared to bacterial meningitis caused by human pathogens, and the incidence has a strong regional distribution. Zoonotic bacterial meningitis is mainly associated with animal contact, consumption of animal products, and an immunocompromised state of the patient. In a high proportion of zoonotic bacterial meningitis cases, CSF analysis showed only a mildly elevated leukocyte count. The recommended antibiotic therapy differs per pathogen, and the overall mortality is low. CONCLUSIONS Zoonotic bacterial meningitis is uncommon but is associated with specific complications. The suspicion should be raised in patients with bacterial meningitis who have recreational or professional contact with animals and in patients living in regions endemic for specific zoonotic pathogens. An immunocompromised state is associated with a worse prognosis. Identification of risk factors and underlying disease is necessary to improve treatment.
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Affiliation(s)
- Anusha van Samkar
- From the Departments of Neurology (A.v.S., M.C.B., D.v.d.B.) and Medical Microbiology (A.v.d.E.), Academic Medical Centre, Centre of Infection and Immunity Amsterdam; and Academic Medical Centre (A.v.d.E.), Netherlands Reference Laboratory for Bacterial Meningitis
| | - Matthijs C Brouwer
- From the Departments of Neurology (A.v.S., M.C.B., D.v.d.B.) and Medical Microbiology (A.v.d.E.), Academic Medical Centre, Centre of Infection and Immunity Amsterdam; and Academic Medical Centre (A.v.d.E.), Netherlands Reference Laboratory for Bacterial Meningitis
| | - Arie van der Ende
- From the Departments of Neurology (A.v.S., M.C.B., D.v.d.B.) and Medical Microbiology (A.v.d.E.), Academic Medical Centre, Centre of Infection and Immunity Amsterdam; and Academic Medical Centre (A.v.d.E.), Netherlands Reference Laboratory for Bacterial Meningitis
| | - Diederik van de Beek
- From the Departments of Neurology (A.v.S., M.C.B., D.v.d.B.) and Medical Microbiology (A.v.d.E.), Academic Medical Centre, Centre of Infection and Immunity Amsterdam; and Academic Medical Centre (A.v.d.E.), Netherlands Reference Laboratory for Bacterial Meningitis.
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Long-Lasting Fever and Lymphadenitis: Think about F. tularensis. Case Rep Med 2015; 2015:191406. [PMID: 26612988 PMCID: PMC4646983 DOI: 10.1155/2015/191406] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 09/30/2015] [Indexed: 11/17/2022] Open
Abstract
We report the case of glandular tularemia that developed in a man supposedly infected by a tick bite in Western Switzerland. Francisella tularensis (F. tularensis) was identified. In Europe tularemia most commonly manifests itself as ulcero-glandular or glandular disease; the diagnosis of tularemia may be delayed in glandular form where skin or mucous lesion is absent, particularly in areas which are assumed to have a low incidence of the disease.
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Abstract
Binary file ES_Abstracts_Final_ECDC.txt matches
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Affiliation(s)
- A Mailles
- Foodborne and zoonotic diseases unit, French Institute for Public Health Surveillance, Saint-Maurice, France
| | - V Vaillant
- Foodborne and zoonotic diseases unit, French Institute for Public Health Surveillance, Saint-Maurice, France
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Ylipalosaari P, Ala-Kokko TI, Tuominen H, Syrjälä H. Guillain–Barré syndrome and ulceroglandular tularemia. Infection 2013; 41:881-3. [DOI: 10.1007/s15010-013-0466-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 04/17/2013] [Indexed: 11/29/2022]
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