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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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Contentin L, Soret J, Zamfir O, Gontier O, Lherm T, Hamrouni M, Ouchenir A, Monchamps G, Kalfon P. Francisella tularensis meningitis. Med Mal Infect 2011; 41:556-8. [DOI: 10.1016/j.medmal.2011.07.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Revised: 05/04/2011] [Accepted: 07/08/2011] [Indexed: 11/28/2022]
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Abstract
Tularemia is a bacterial infection usually transmitted via arthropod vectors or direct contact with infected animals. Naturally occurring cases are relatively rare, and can result in six different clinical syndromes. Tularemia is also a potential agent of bioterrorism or biowarfare, and is categorized as a high-level threat. Effective antibiotic treatment is available, including potential use of oral antibiotics in a mass casualty situation. An awareness of potential clinical presentations of tularemia will facilitate timely intervention,appropriate diagnostic testing, and decreased morbidity in the event of a biologic attack with Francisella tularensis.
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Affiliation(s)
- Steven D Cronquist
- Department of Dermatology, Naval Hospital Great Lakes, 3001A Sixth Street, Great Lakes, IL 60088, USA.
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Abstract
The zoonotic infections caused by Francisella tularensis and Coxiella burnetii, tularemia and Q fever, respectively, are two less commonly encountered clinical illnesses that are becoming increasingly recognized as epidemiologically important human diseases. The prevalence of tularemia and Q fever can be positively impacted by increased awareness of the clinical entities that arise from infection by these arthropod-borne organisms. Improved recognition of these clinical syndromes will lead to greater diagnostic accuracy in recognizing these diseases in patients. Ultimately, more stringent measures to prevent infection may be required, through raising public awareness, since current therapeutic regimens for these two diseases are limited, and knowledge of the pathogenesis of these two organisms are still in developing stages.
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Affiliation(s)
- Elisa Choi
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA. echo:@caregroup.harvard.edu
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