5-103
Percussion: Acute (< 2 hr); Sub acute (2-48 hr) Typhoidal form: Enlarged liver and spleen; pneumonic form:
Signs of consolidation (dullness to percussion), egophony.
Assessment:
Differential Diagnosis:
Meningococcal infection - rapidly progressive; petechial to purpuric rash; often with meningeal signs; no tick
or animal exposure
Rickettsial infection - febrile illness with rash after tick bite; not likely to have suppurative lymphadenopathy or
skin ulcers
Cat scratch disease - can be confused with ulceroglandular tularemia, history of cat scratch and lack of risk
factors for tularemia
Sporotrichosis - history of thorn/cactus/plant related injury to body; lymphangitis seen commonly with
sporotrichosis while it is less common with oculoglandular tularemia
Syphilis - sexual contact; genital ulcer, which is painless; patient often afebrile
Lymphogranuloma venereum - sexually transmitted infection; can cause regional and generalized adenopathy
with genital ulcer; less likely to have ulcer elsewhere on body
Other less likely possibilities are cutaneous tuberculosis, plague and anthrax.
Plan:
Treatment
Primary: Gentamicin 5 mg/kg/day divided q 8 hrs IV or IM for 7-10 days. Due to risk of renal toxicity, ensure
adequate hydration and urine output. If in doubt, use alternate drug.
Alternative: Tetracycline 500 mg q 6 hrs until fever breaks, then 250 mg qid for 5-7 days (higher relapse
than gentamicin)
Primitive: Wet saline dressings to skin lesions or eyes for comfort.
Empiric: Cover with ceftriaxone 1 gm q 12 hrs and gentamicin as above, and transport to definitive care.
NOTE: Tetracycline 250 mg po qid for 2 weeks is an effective prophylaxis after exposure to tularemia.
Patient Education
General: This organism can live for a long time, even frozen in carcasses, water and mud.
Activity: As tolerated
Prevention and Hygiene: Avoid ticks; handle rodents/rabbits with protective clothing, including gloves;
thoroughly cook wild birds and game; disinfect drinking water
Follow-up Actions
Consultation Criteria: Patients with suspected tularemia should be transported to hospital for further care
and treatment. This infection usually requires consultation to make diagnosis. Serology is available and
suggests diagnosis if titer >1:160 after 10 days of illness, however it cross-reacts with Brucella.
Zoonotic Disease Considerations
Principal Animal Hosts: Rodents, rabbits, cats, sheep
Clinical Disease in Animals: Sudden onset of high fever, lethargy, anorexia, reduced mobility, stiffness;
increased pulse and respiratory rate; coughing, diarrhea and pollakiuria may develop; prostration and death
in a few days.
Probable Mode of Transmission: Ingestion, inhalation, occupational exposure, insect bites
Known Distribution: Circumpolar in America, Europe, Asia