Ulceroglandular Tularemia Following Contact with a Boar

Tularemia treatment: experimental and clinical data

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.

PEDIATRIC TULAREMIA– A CASE SERIES FROM A SINGLE CENTER IN SWITZERLAND

Background

The incidence of tularemia has recently increased throughout Europe. Pediatric tularemia typically presents with ulceroglandular or glandular disease and requires antimicrobial therapy not used in the empirical management of childhood acute lymphadenitis. We describe the clinical presentation and course in a case series comprising 20 patients.

Methods

This is a retrospective analysis of a single-center case series of microbiologically confirmed tularemia in patients <16 years of age diagnosed between 2010 and 2021.

Results

Nineteen patients (95%) presented with ulceroglandular (n = 14) or glandular disease (n = 5), respectively. A characteristic entry site lesion (eschar) was present in 14 (74%). Fever was present at illness onset in 15 patients (75%) and disappeared in all patients before targeted therapy was initiated. The diagnosis was confirmed by serology in 18 patients (90%). While immunochromatography was positive as early as on day 7, a microagglutination test titer 1:≥160 was found no earlier than on day 13. Sixteen patients (80%) were initially treated with an antimicrobial agent ineffective against F. tularensis. The median delay (range) from illness onset to initiation of targeted therapy was 12 (6–40) days. Surgical incision and drainage were ultimately performed in 12 patients (60%).

Conclusions

Pediatric tularemia in Switzerland usually presents with early, self-limiting fever and a characteristic entry site lesion with regional lymphadenopathy draining the scalp or legs. Particularly in association with a tick exposure history, this presentation may allow early first-line therapy with an agent specifically targeting F. tularensis, potentially obviating the need for surgical therapy.

Tularemia: an experience of 13 cases including a rare myocarditis in a referral center in Eastern Switzerland (Central Europe) and a review of the literature

BACKGROUND

Tularemia, a zoonotic disease caused by Francisella tularensis, can cause a broad spectrum of disease in humans including six major clinical presentations: the ulceroglandular, glandular, oculoglandular, oropharyngeal, typhoidal and pneumonic form. The epidemiology and ecology and thus transmission of tularemia are complex, depending on conditions unique to specific locations.

CASE SERIES AND METHODS

Thirteen cases with different forms of the disease and one very rare case of a myocarditis are reported, discussed, and reviewed within the scope of current literature.

CONCLUSION

Tularemia is a rare, but emerging disease in Central Europe with glandular and ulceroglandular disease as its predominant forms. Transmission is mainly caused by contact with lagomorphs, rodents and tick bites. However, domestic cats may play an important role in transmission too. Myocarditis is probably a worldwide, but very rare manifestation of tularemia.

Dermatological aspects of tularaemia: a study of 168 cases

BACKGROUND

Tularaemia is a zoonotic infectious disease caused by Francisella tularensis, an aerobic, uncapsulated, gram-negative coccobacillus. Several case reports have appeared on the dermatological manifestations of tularaemia, but relatively few longer-term studies are available.

AIM

To identify skin features of tularaemia that aid in its diagnosis.

METHODS

In total, 168 patients (68 male, 100 female) diagnosed with tularaemia were retrospectively examined. All dermatological data for these patients were evaluated.

RESULTS

Of the 168 patients, 149 (88.69%) had tularaemia of the oropharyngeal type, 12 (7.73%) had the ulceroglandular type, 5 (2.9%) had the oculoglandular type and 2 (0.59%) had the pulmonary type. Secondary skin manifestations were found in 26 patients (15.47%). Sweet syndrome (SS) was found in 11 patients (6.54%), most of whom presented with the oropharyngeal form, while erythema nodosum (EN) was found in 7 patients (4.16%), dermatitis in 2 (1.19%), urticaria in 2 (1.19%), acneiform eruptions in 1 (0.59%), vasculitis-like eruptions in 1 (0.59%) and SS + EN in 1 (0.59%). Patients with the oropharyngeal form had a statistically significant (P < 0.001) higher number of skin findings than patients with the other forms.

CONCLUSIONS

In clinical practice, tularaemia may present with various cutaneous manifestations, and dermatologists who work in endemic regions must be aware of the possibility of this disease.