Primary pneumonic plaguefrom inhalation of infected droplets manifests itself with
sudden onset of fever, chills, headache, chest pain, shortness of breath, hypoxia, and
hemoptysis. Death can occur in the first 24 hours of disease.
Pharyngitisfrom inhalation or ingestion may be asymptomatic (colonization in contacts of
patients with plague pneumonia) or present with swollen tonsils and/or inflamed cervical nodes.
Diagnosis: Blood and site-specific cultures and direct fluorescent antibody (DFA) testing
of tissue or fluids. Real time polymerase chain reaction (PCR) of sputum can rapidly detect
organism in the experimental setting.
Differential diagnosis: Plague must be differentiated from other forms of sepsis. The
differential diagnosis for plague pneumonia includes all causes of bilateral pneumonia,
tularemia, Q fever, mycoplasma, Legionnaires’ disease (especially in the presence of diarrhea),
tuberculosis, fungal infections, and viral pneumonias.
Treatment: Streptomycin is the drug of choice. Gentamicin, doxycycline, chlorampheni-
col, and ciprofloxacin are alternate agents. Treatment is for at least 10 days.
Prophylaxis (adult dosing): Prophylaxis should be administered for seven days after the
last exposure. The preferred agents are doxycycline (100 mg PO b.i.d.) or ciprofloxacin (500 mg
PO b.i.d.).
Tularemia (1,30)
Incubation period: The average incubation period after any of the exposures is three to six days
(range a few hours to three weeks).
Contagious period: Natural infection is acquired by contact with infected animals,
especially rodents and rabbits, arthropod, insect and tick bites, inhalation, and ingestion. The
organism is not transmitted from person-to-person. Clinical specimens represent a risk.
The laboratory must be notified so that no procedures are carried out at an open bench.
Clinical disease: Patients present with an abrupt onset of fever, chills, myalgia, headache,
and often a dry cough in all forms of the disease. A papular rash or erythema nodosum is
common.
Ulceroglandular or Glandular Tularemia
Papule at site of entry progresses to a slow-healing crusting ulcer with the development of
tender regional lymphadenopathy. Glandular tularemia lacks the ulcer.
Oropharyngeal Tularemia
Occurs after ingestion of contaminated food or water. Patients present with ulcerative
tonsillitis or pharyngitis, often unilateral, with regional lymphadenopathy.
Oculoglandular Tularemia
This is similar to ulceroglandular disease except the primary lesion is in the conjunctivae.
There is usually severe unilateral conjunctivitis with enlargement of the preauricular nodes.
Typhoidal Tularemia
Patients present with the same general symptoms, high fever with relative bradycardia,
gastrointestinal symptoms, and pneumonia. There are no focal signs. The disease may be self-
limited or a life-threatening sepsis.
Pneumonic Tularemia
Contracted through inhalation or secondary to sepsis. Patients may have infiltrates, hilar
adenopathy, pleural effusions, or necrotizing pneumonia.
Diagnosis: Diagnosis is usually confirmed by acute and convalescent serology. PCR,
culture, and lymphocyte stimulation testing have also been used to confirm the diagnosis
where serology has failed.
478 Cleri et al.