Tularemia: Current, comprehensive information on pathogenesis, microbiology, epidemiology, diagnosis, treatment, and prophylaxis

Last updated March 16, 2010

Agent and Pathogenesis
Epidemiology
Tularemia as a Biological Weapon
Clinical Syndromes and Differential Diagnosis
Clinical Laboratory Testing
Treatment, Postexposure Prophylaxis, and Vaccines
Hospital Infection Control (Including Autopsies and Burial)
Public Health Reporting and Case Definitions
Recognition of Unusual Events
Images
References

Agent and Pathogenesis

Agent

Microbiological characteristics

Tularemia is caused by Francisella tularensis (formerly Pasteurella tularensis). Key microbiological characteristics include the following (see References: CDC/ASM/APHL 2001, Cross 2000, Penn 2010, Sneath 1986, Wong 1999).

Tiny, faintly staining, pleomorphic gram-negative coccobacillus (0.2-0.5 mcm x 0.7-1.0 mcm); smaller in patient samples than in culture; may be confused with Haemophilus or Actinobacillus species
Difficult to see by light microscopy in blood, tissue samples, or other specimens that contain significant background material
Nonsporulating, nonmotile
Aerobic (obligatory)
Requires cysteine (or cystine or another sulfhydryl source) for growth (although atypical strains that lack this requirement have been identified [see References: Bernard 1994])
Grows on commercial blood culture media, but does not grow (or grows unreliably) on most other standard agar media
Visible growth on appropriate media requires 2 to 5 days
Weakly catalase-positive (although may be negative); oxidase-negative
Thin, lipid-rich capsule
Distinctive cellular fatty-acid profile

Other characteristics of F tularensis include the following:

Wild-type F tularensis strains generally are susceptible to aminoglycosides (streptomycin, gentamicin, kanamycin), tetracyclines, chloramphenicol, and fluoroquinolones.
F tularensis strains generally are resistant to beta-lactam antibiotics, owing in part to beta-lactamase activity.
Organisms can persist for long periods in moist environments like water, mud, and decaying animal carcasses.
Ingestion of F tularensis by environmental amoebas may affect the bacterial ecology by:

Increasing environmental resistance
Increasing virulence (see References: Berdal 1996)

Subspecies

There are four subspecies of F tularensis. These subspecies (subsp) can be differentiated by biochemical and molecular tests, and the current taxonomy is as follows (see References: Ellis 2002, Kugeler 2006, Morner 1993, Whipp 2003):

F tularensis subsp tularensis (type A) (see References: Farlow 2005, Johansson 2004, Petersen 2006, Svensson 2005):

Highly infectious, generally more virulent, and more genetically diverse than subsp holarctica
Found primarily in North America
Demonstrates citrulline ureidase activity
Produces acid from glycerol fermentation
Two distinct genetic clades have been identified. The geographic distribution of the two clades in human cases correlates with the distribution of arthropod vectors and rabbit hosts (see References: Farlow 2005, Kugeler 2009):

Clade 1 (aka subpopulation 1, A.I, A1, type A-east) occurs primarily in the central United States, is associated with the distribution of Amblyomma americanum (the Lone Star tick) and Dermacentor variabilis (the American dog tick), and appears to have a high case-fatality rate.

Genotypes A1a and A1b recently have been identified.
Infection with A1b is associated with higher mortality than A1a.

Clade 2 (aka subpopulation 2, A.II, A2, type A-west) occurs primarily in the western United States, is associated with the distribution of Dermacentor andersoni (the Rocky Mountain wood tick) and Chrysops discalis (the deer fly), and has a low case-fatality rate.

Genotypes A2a and A2b recently have been identified.
No difference in mortality has been observed between infections caused by A2a and A2b.

Strains of both major clades have been fully sequenced (see References: Beckstrom-Sternberg 2007, Larsson 2005).

F tularensis subsp holarctica (type B): Less virulent than subsp tularensis, does not demonstrate citrulline ureidase activity, and does not produce acid from glycerol fermentation; three biovariants (biovars) have been identified:

Biovar I: erythromycin sensitive; primarily found in North America, Europe, Siberia, the Far East, and Kazakhstan
Biovar II: erythromycin resistant; primarily found in Eurasia
Biovar japonica: found in Japan

F tularensis subsp mediaasiatica: Found in the Central Asian republics of the former Soviet Union (virulence is similar to subsp holarctica); produces acid from glycerol and thus may be confused with subsp tularensis (see References: Sandstrom 1992).
F tularensis subsp novicida: Considered to be of low virulence and generally causes illness only in immunocompromised hosts (see References: Titball 2003); produces acid from glycerol and thus may be confused with subsp tularensis [see References: Cross 2000, Hollis 1989, Sjostedt 2003, Titball 2003, Whipp 2003]) Note: F tularensis and F novicida traditionally have been considered separate species; however, the current approach is to consider F novicida as a subspecies of F tularensis.

Other Francisella species

Other Francisella species may be confused with F tularensis in clinical or environmental samples.
F philomiragia is the only other taxonomically defined species in the genus other than F tularensis. It is halophilic, rarely associated with human disease, and difficult to identify by conventional methods (see References: Ellis 2002, Friis-Moller 2004, Whipp 2003).
Undefined Francisella-like bacteria appear to be common in the environment (see References: Barns 2005).
Investigators have identified a novel Francisella species in ixodid ticks in some regions. This discovery highlights the need for careful analysis of polymerase chain reaction (PCR)-based identification (see References: Sreter-Lancz 2008).

Pathogenesis

Virulence factors that contribute to the pathogenesis of F tularensis have not been well defined, and further studies are needed; however, key points on pathogenesis are outlined below (see References: Ellis 2002, Sjostedt 2003, Titball 2003):

F tularensis is a facultative intracellular pathogen that multiplies predominantly within macrophages. The organisms initially enter macrophages through phagocytosis by a novel process of engulfment within asymmetric pseudopod loops and then disrupt the phagosomal membrane to gain direct access to the cytoplasm (see References: Clemens 2004).
F tularensis virulence is determined in part by the ability of the organisms to replicate within macrophages. Bacteria are released from the macrophage following cell death by apoptosis. A recent study using a murine model demonstrated high levels of F tularensis in the plasma of infected mice. On the basis of this finding, the authors suggest that F tularensis in theblood of infected hostsis taken upby and replicates withinleukocytes and eventually escapes intothe plasma, where itpropagates a cycle ofinfection, escape, and reinfection (see References: Forestal 2007).
The capsule appears to be necessary to protect against serum-mediated lysis but is not required for survival following phagocytosis.
The lipopolysaccharide (LPS) does not exhibit the properties of a classic endotoxin and demonstrates low toxicity in vivo and in vitro, although LPS may have a role in macrophage growth.
The presence of type IV pili appears to be a virulence factor and may be particularly important for F tularensis infections that occur via the peripheral route. Direct repeat-mediated deletion of genes coding for type IV pili results in major virulence attenuation (see References: Forslund 2006).

Pathologic features for the various clinical syndromes caused by F tularensis have been described and are briefly summarized below.

Glandular and ulceroglandular tularemia

In both glandular and ulceroglandular tularemia, organisms enter the skin through the bite of infective arthropods, direct contact with infectious materials (such as contaminated carcasses), or percutaneous inoculation with a sharp object (such as a bone fragment from a contaminated carcass).

Organisms can enter through inapparent breaks in the skin surface.
The infectious dose for humans following percutaneous or inhalational inoculation is 10 to 50 organisms (see References: Cross 2000, Penn 2010).
In the ulceroglandular form, the organisms proliferate locally and cause a papule to develop at the site of inoculation within 3 to 5 days after initial exposure (see References: Cross 2000, Penn 2010).

The papule develops as a result of a localized inflammatory response that involves fibrin, neutrophils, macrophages, and T lymphocytes.
The initial inflammatory nidus becomes necrotic and degenerates over the next several days, thereby forming a tender ulcerated lesion at the site of the papule.
The ulcer is typically 2 to 4 cm in diameter and has an irregular and raised border.
A dark scab (which may resemble the characteristic eschar of anthrax) may occur over the area of ulceration.
Organisms spread from the site of inoculation to regional lymph nodes, where they cause necrotizing lymphadenitis surrounded by a neutrophilic and granulomatous inflammatory infiltrate (see References: CDC 2004). Granulomas may develop in lymph nodes as the inflammatory process progresses; these may eventually coalesce to form abscesses. Follicular hyperplasia and inflammatory cell infiltrates involving predominantly granulocytes often are noted (see References: Sutinen 1986).
Affected lymph nodes may become fluctuant, rupture, and sometimes create draining sinus tracts in the skin.
Organisms may disseminate via hematogenous spread to involve multiple organs, and sepsis syndrome can occur.

In glandular tularemia, regional lymph node involvement occurs, but ulceration at the site of inoculation is absent.

Pneumonic tularemia

Organisms enter the lungs either through inhalation of infectious aerosols or through hematogenous spread. The infectious dose by the respiratory route is 10 to 50 organisms (see References: Franz 1997, Saslow 1961).

Once in the lungs, the organisms rapidly enter pulmonary macrophages (within minutes) and begin replicating. The explosive replicative capacity of F tularensis appears to be an important factor in virulence associated with pulmonary infection (see References: Malik 2006). An intense accumulation of inflammatory cells, particularly neutrophils and macrophages, can be seen at sites of bacterial replication. The influx of neutrophils appears to play more of a destructive than protective role in the host response.

The following features have been noted for pneumonic tularemia (see References: Lillie 1937, Stuart 1945, Syrjala 1986):

Ulcerative bronchitis and bronchiolitis
Hemorrhagic edema with a nonspecific inflammatory response consisting of lymphocytes, plasma cells, and eosinophils (early in the clinical course)
Discrete nodules with acute suppurative necrosis of lung parenchyma
Alveolar exudates involving mononuclear cells, fibrin, and red blood cells
Nodular, segmental, or lobar consolidation
Caseous or cavitary lesions (late in the clinical course)
Granuloma formation (late in the clinical course)
Pleural fibrinous, fibrinocellular, or fibrinocaseous exudation
Hilar lymphadenopathy

Oculoglandular tularemia

Organisms gain entry via the conjunctiva.
Superficial necrosis and ulceration of the conjunctiva occur, often accompanied by lymphocytic infiltration. Papules also may be noted (see References: Lillie 1937).
Granulomatous nodules may develop over time (see References: Lillie 1937).
Organisms spread from the conjunctiva to the preauricular, submandibular, or cervical lymph nodes, where they cause focal necrosis and lesions similar to those noted with ulceroglandular tularemia.
Infection most commonly is unilateral.

Oropharyngeal tularemia

Organisms enter the mucous membrane of the oropharynx following ingestion or inhalation of organisms.
Exudative pharyngitis or tonsillitis usually occurs, and ulcers may develop.
Organisms spread to the cervical lymph nodes, where necrosis and suppuration may occur.

Typhoidal tularemia

Typhoidal tularemia involves a systemic illness without anatomic localization of infection.
Organisms enter the bloodstream through breaks in the skin or through mucous membranes and may affect the lungs and reticuloendothelial organs (ie, lymph nodes, liver, spleen, bone marrow).
Necrotic foci can occur in any involved organ, and caseating granulomas may develop.
Sepsis may occur, leading to shock, organ system failure, adult respiratory distress syndrome, and disseminated intravascular coagulation.

Epidemiology

Reservoirs, Vectors, and Modes of Transmission

Reservoirs

Small and medium-sized mammals are the principal natural reservoirs for F tularensis. Examples include (see References: Dennis 1998, Gelman 1961, Hopla 1974):

Lagomorphs (rabbits, hares) (predominantly North America, Europe, Japan)
Aquatic rodents (beaver, muskrats, water voles)
Field voles
Water and wood rats
Squirrels
Lemmings (former Soviet Union, Sweden, Norway)
Meadow and field mice (predominantly former Soviet Union)

Humans, other mammalian species (eg, cats, dogs, cattle, primates), and some species of birds, fish, and amphibians are incidental hosts.

A serologic survey of 91 cats in Connecticut and New York found that 12% had antibodies to F tularensis (see References: Magnarelli 2007).
An outbreak of tularemia in commercially distributed prairie dogs was recognized in the United States in 2002 (see References: CDC 2002: Outbreak of tularemia among commercially distributed prairie dogs, 2002; Petersen 2004). Serologic testing of potentially exposed persons demonstrated that one person (an animal handler) had a positive F tularensis titer of 1:128 on initial testing that subsequently declined to 1:32 on follow-up testing at 4 and 6 months, suggesting prairie dog–to-human transmission (see References: Avashia 2004).
Outbreaks also have occurred in nonhuman primates housed outdoors. In a German primate facility, 18 of 35 cynomolgus monkeys (Macaca fasicularis) contracted tularemia within a 2-year period; 6 of the animals died (see References: Matz-Rensing 2007).

Information from studies conducted on Martha's Vineyard suggests that F tularensis can persist in the environment and that persons can acquire infection by engaging in activities that lead to aerosolization (such as lawn mowing, weed-whacking, and using a power blower) (see References: Feldman 2001, Feldman 2003). An analysis of sera from a variety of mammals on Martha’s Vineyard found that skunks and raccoons were frequently seroreactive (49% of skunks tested and 52% of raccoons), whereas white-footed mice, cottontail rabbits, deer, rats, and dogs were much more likely to be seronegative (see References: Berrada 2006).

During the fall and winter of 2003, F tularensis was identified on several filters from a biodetection air-monitoring system in Houston, Texas (see Oct 10, 2003, CIDRAP News story). An investigation conducted at that time supported contamination of the filters by naturally occurring F tularensis organisms, although the environmental reservoir was not definitively identified.

Diverse bacteria, including select agents, have been detected in urban air by DNA arrays during a 17-week study of airborne bacterial composition and dynamics in Austin and San Antonio, Texas. Although taxonomic clusters containing organisms closely related to Francisella were found, F tularensis was never encountered (see References: Brodie 2007).

In a study of natural outbreaks of human tularemia in two locations in Sweden, genotyping of F tularensis subsp holarctica isolates was used in conjunction with information obtained from patients to investigate the epidemiology and geographic spread of disease. Strong, highly localized spatial associations were found between F tularensis subpopulations and places of disease transmission, indicating likely point sources of infection. Most patients were infected from mosquito bites. Disease clusters were linked to recreational areas near water, and identical subtypes were present throughout the tularemia season and persisted over different years (see References: Svensson 2009). As with the studies on Martha's Vineyard, these findings support persistence of F tularensis in the environment over time.

F tularensis appears to survive within Acanthamoeba (relatively ubiquitous protozoa), suggesting that these organisms may serve as a reservoir for F tularensis. Survival within Acanthamoeba may provide a mechanism for F tularensis to persist in the environment (see References: Abd 2003).

Vectors

A number of different arthropod vectors that transmit F tularensis have been identified (see References: Dennis 1998, Hopla 1974).
Primary vectors are ticks (United States, former Soviet Union, and Japan), mosquitoes (former Soviet Union, Scandinavia, and the Baltic region), and biting flies (United States [particularly Utah, Nevada, and California] and former Soviet Union). Examples of specific species include:

Ticks: A americanum (Lone Star tick), D andersoni (Rocky Mountain wood tick), D variabilis (American dog tick), Ixodes scapularis, I pacificus, and I dentatus
Mosquitoes: Aedes cinereus and A excrucians
Biting flies: C discalis (deer fly), C aestuans, C relictus, and Chrysozona pluvialis

Modes of transmission

The average incubation period is 3 to 5 days. F tularensis can be transmitted to humans via various mechanisms:

Bites by infected arthropods (see References: Klock 1973, Markowitz 1985)
Direct contact with infected animals
Handling of infectious animal tissues or fluids (see References: Young 1969)
Ingestion of contaminated food, water, or soil (see References: Barut 2009, Greco 1987, Mignani 1988, Reintjes 2002, Willke 2009); murine models have confirmed that F tularensis is an effective oral pathogen and may pose a hazard, particularly to immunocompromised individuals, if ingested in contaminated food or water (see References: KuoLee 2007)
Possibly direct contact with contaminated soil or water
Inhalation of infectious aerosols, including dust from contaminated hay (see References: Dahlstrand 1971) and aerosols generated by lawn mowing and brush cutting (see References: Feldman 2001, Feldman 2003)
Exposure in the laboratory setting (eg, inhalation of infectious aerosols, handling cultures or other infectious materials, accidental percutaneous exposure) (see References: Overholt 1961, Pike 1976)

Person-to-person transmission has not been documented.

Naturally Occurring Tularemia in the United States

Historical perspective

Colloquial terms for human illness associated with F tularensis include "rabbit fever," "deerfly fever," and "lemming fever."
Most US cases in recent years have been associated with bites from infected arthropods, although rabbits, hares, and other small mammals continue to be major sources of exposure for cases in the southeastern United States (see References: Dennis 1998).
During the 1930s, 2,000 or more cases were reported annually. Since that time, reported case numbers have gradually declined.
During the 1990s, the mean number of cases reported each year was 124 (although this number likely does not reflect actual incidence since many cases either are not reported or are not accurately diagnosed) (see References: CDC 2002: Tularemia—United States, 1990-2000). Tularemia was reported in all US states except Hawaii. States with the highest number of reported cases during these years were Arkansas, Missouri, Oklahoma, Kansas, South Dakota, and Montana. Martha's Vineyard also had a high number of identified cases. Reported incidence rates were higher in males than in females, with the highest rates reported for children 5 to 9 years old and persons 75 years of age or older.
Traditionally, most cases have occurred in rural or semirural environments; cases rarely occur in urban settings.
In the United States, cases occur most commonly between May and August, although cases can occur during any time of year (see References: CDC 2002: Tularemia—United States, 1990-2000).
Data from a study of cases in the United States from 1964 through 2004 indicate that type A and type B infections differ in terms of affected populations, anatomic site of isolation, and geographic distribution. Molecular subtyping and pulsed-field gel electrophoresis (PFGE) defined two clades of type A organisms (A1 [type A-east] and A2 [type A-west]) that differ in geographic distribution, disease outcome, and transmission (see References: Staples 2006).

Type A2 infections were less severe than either type B or type A1 infections. The case-fatality rate for type A1 was 14%, for type B was 7%, and for type A2 was 0%.
Type B infections clustered along major waterways, including the upper Mississippi River, and areas with high rainfall, such as the Pacific Northwest.
Type A1 infections occurred in Arkansas, Missouri, Oklahoma, and along the Atlantic Coast east of the Appalachians.
Type A2 infections occurred predominantly in the arid regions of the southwestern United States.
Occasionally, more than one subspecies or subtype can be identified in a localized outbreak. In a deer-fly associated outbreak involving five human cases in Utah in 2007, human infections arose from either type A1 or A2 (F tularensis subsp tularensis). Animal carcasses collected in the area harbored type A1, A2, or B organisms (F tularensis subsp holarctica) (see References: Petersen 2008).

In the previously described study by Staples et al (see References), only 20% of the type A isolates were genotyped. Subsequently, PFGE was performed on all of the type A (n=302) and a portion of the type B (n=61) human and animal isolates. Molecular subtyping of these isolates identified four distinct type A genotypes, A1a, A1b, A2a, and A2b, as well as type B. The geographic distribution of human infections by genotype closely matched that for animals. Significantly higher mortality was observed for human infections due to genotype A1b (24%), compared with those caused by A1a (4%), A2 (0%), and type B (7%) (see References: Kugeler 2009).
Climate change may affect future distribution of tularemia. Modeling studies suggest that, as the climate warms, the southern border of tularemia distributions in the United States will shift northward about 600 km. This could mean a reduced incidence in the south central United States (eg, Louisiana, Mississippi) and a greater incidence in north central states (eg, Michigan to North Dakota) (see References: Nakazawa 2007). Combined environmental and tularemia-incidence data have been used to develop a multivariate logistic regression model for predicting areas that have increased disease risk (see References: Eisen 2008).

Outbreaks

Outbreaks of tularemia occasionally have been recognized in the United States; examples include the following:

Martha's Vineyard, 2000: Fifteen cases of tularemia were reported; 11 patients had primary pneumonic disease and 1 patient died (see References: Feldman 2001). Illness was caused by F tularensis, type A. Patients were more likely than controls to have used a lawn mower or brush cutters in the 2 weeks before illness onset.
South Dakota, 1984: Twenty cases of glandular tularemia were reported in children and young adults on Crow Creek Indian reservations in the state (see References: Markowitz 1985). Illness was mild (fever, headache, and lymphadenopathy) and was presumably caused by F tularensis, type B. A similar outbreak occurred in 1979 on the Crow Indian Reservation in Montana, where 12 cases were identified (see References: Schmid 1983: Clinically mild tularemia associated with tick-borne Francisella tularensis).
Utah, 1971: Thirty-nine cases of tularemia were reported; most patients contracted illness from the bite of an infected deerfly (see References: Klock 1973). Clinical features included cutaneous ulcers at the site of a bite, lymphadenopathy, fever, chronic malaise, and weakness; all patients recovered. Strain type was not reported.
Vermont, 1968: Forty-seven cases of tularemia were diagnosed in persons who had handled muskrats in the 4 weeks before illness onset (see References: Young 1969). No fatalities were reported, but 14 patients had a severe prostrating illness that lasted an average of 10 days. Strain type was not reported.

Naturally Occurring Tularemia Worldwide

Outside the United States, the incidence of disease is highest in Scandinavian countries and Russia (see References: Dennis 1998). In central Europe, analysis of populations in low-risk areas suggests that the disease incidence may be seriously underestimated (see References: Splettstoesser 2009).
Tularemia is endemic in neoarctic and paleoarctic regions between the latitudes of 30° and 71° N (ie, North America, Europe, states of the Russian Federation, China, and Japan [see References: Dennis 1998]).
Outbreaks involving a number of countries in Europe and nearby regions have been reported (see References: Christenson 1984, Dahlstrand 1971, Eliasson 2002, Greco 1987, Gurycova 2006, Kantardjiev 2006, Perez-Castrillon 2001, Reintjes 2002, Siret 2006, Syrjala 1985). Highlights include the following:

Sweden periodically has years of heavy tularemia activity. In 2003, 698 cases were reported, with a peak in August (300 cases) and September (164 cases). Other years of heavy activity include 1967, 1970, 1981, and 2000 (see References: Payne 2005). A large outbreak (90 cases) occurred in central Sweden in 2006 (see References: Wik 2006).
An outbreak in the Castilla y Leon region of Spain resulted in more than 500 cases of tularemia in the fall of 2007. The outbreak is thought to have arisen from unusual climatic and environmental circumstances, which produced suitable conditions for propagation of F tularensis. Many of the cases were involved in harvesting and related farm work, which likely contributed to production of aerosols that transported the bacteria (see References: Allue 2008, Martin 2007).
Outbreaks occurred in five provinces in northwestern Turkey during 2004 and 2005. Another outbreak was observed in the Middle Black Sea Region of Turkey in 2005, and was confined to a large, extended family living in the same house. Microagglutination assays were performed on serum samples from all members of the family. Eight of the 16 family members were found to be positive for tularemia serologically, resulting in an attack rate of 50%. Epidemiologic and environmental findings suggested that contaminated water or food was the cause of these outbreaks (see References: Barut 2009, Celebi 2006, Gurcan 2006, Willke 2009).
During a recent large tularemia outbreak in Bulgaria, a hunter acquired tularemia through a scratch from a buzzard at a location approximately 100 km from the epidemic focus. No other human or animal cases had been recorded in the hunting region. The isolate from the hunter was found to be identical to one of the four outbreak genotypes. These findings suggest bird-to-human transmission of F tularensis and the role of birds in dissemination of the disease (see References: Padeshki 2010).

Tularemia as a Biological Weapon

F tularensis is considered a category A bioterrorism agent (see References: CDC: Bioterrorism agents/diseases). The following information supports the use of F tularensis as a potential biological weapon (see References: CDC: Key facts about tularemia, Christopher 1997, Dennis 2001).

F tularensis is highly infectious, occurs widely in nature, and can be isolated and grown in quantity in the laboratory.
During World War II, the Japanese conducted research on F tularensis as a biological weapon.
During the 1950s and 1960s, the United States developed weapons that could deliver aerosolized F tularensis organisms. The United States government stockpiled weaponized tularemia until stockpiles were destroyed in 1973.
The former Soviet Union also weaponized F tularensis; the Soviet program included development of antibiotic- and vaccine-resistant strains.
In 1969, the World Health Organization estimated that an aerosol dispersal of 50 kg of virulent F tularensis over a metropolitan area with 5 million inhabitants in a developed country would result in 250,000 illnesses, including 19,000 deaths.

The most likely form of intentional release for F tularensis organisms would be via infectious aerosols. An aerosol release would be expected to cause the following clinical syndromes:

Many of the patients would present with primary pneumonic tularemia; however, some would present with a nonspecific febrile illness of varying severity (ie, typhoidal tularemia).
Cases of oculoglandular tularemia could occur from eye contamination.
Cases of glandular or ulceroglandular disease could occur through exposure of broken skin to infectious aerosol.
Cases of oropharyngeal disease also could occur through inhalation of organisms.

An outbreak of tularemia caused by a bioterrorist attack would be expected to have the following features:

The incubation period generally correlates with the virulence of the infecting strain; in a bioterrorist attack, a highly virulent strain with a relatively short incubation period likely would be used. Illness onsets would generally occur 3 to 5 days after the initial release but could occur as soon as 1 day and up to 14 days later.
Illness would probably occur in an urban area and not in rural regions (where naturally occurring tularemia would be more prevalent).
Patients would not have risk factors for tularemia exposure (eg, outdoor field work, recent outdoor recreational activity, agricultural exposures, exposure to tissues of potentially infected animals).

In the event of a bioterrorist attack, use of F tularensis strains with enhanced virulence or antimicrobial resistance is of concern; therefore, past experience may not be a valuable predictor of disease severity under such circumstances.

Some animals might serve as sentinels of certain bioterrorism agents, including Bacillus anthracis and Yersinia pestis. While animals are not likely to provide early warning for a bioterrorist event caused by F tularensis, a recent review indicates that animals (such as prairie dogs, other rodents, raccoons, skunks, and cats) could serve as markers for ongoing exposure risk following a tularemia bioterrorist event or could propagate or maintain an epidemic (see References: Rabinowitz 2006).

Clinical Syndromes and Differential Diagnosis

Clinical Syndromes

Overview

F tularensis infection can cause the following clinical syndromes (see References: Dennis 1998):

Glandular tularemia (10% to 25% of naturally occurring cases)
Ulceroglandular tularemia (45% to 85% of naturally occurring cases)
Pneumonic tularemia (<5% of naturally occurring cases, although outbreaks following inhalational exposure have been reported; secondary pneumonia [often associated with the typhoidal form] occurs relatively frequently and results from hematogenous spread to the lungs)
Oculoglandular tularemia (<5%)
Oropharyngeal tularemia (<5%)
Typhoidal tularemia (<5%, although in outbreaks caused by aerosol exposure, this percentage may be much higher)

Tularemia can range from a mild infection to a life-threatening illness.

Before antibiotic therapy was available, the overall case-fatality rate was approximately 7%, although rates as high as 50% were seen with pneumonia and other forms of severe infection (see References: Dennis 2001, Pullen 1945).
Currently, case-fatality rates are low (approximately 2%) (see References: Evans 1985).
Most patients respond rapidly to appropriate antibiotic therapy, with fever and generalized symptoms improving in 24 to 48 hours.
Type A tularemia is more severe than type B, which is generally a mild illness.
One study identified the following factors as associated with a poor outcome (ie, death, relapse, prolonged recovery) (see References: Penn 1987):

Underlying comorbidity (eg, alcoholism, diabetes)
Delay in seeking medical care
Delay in instituting appropriate antibiotic therapy

Clinical features for the major syndromes caused by F tularensis are outlined in the tables below. Initial signs and symptoms can be relatively nondescript, and the diagnosis may be missed (see References: Dembek 2003). One study describes two cases of human infection with F tularensis that were initially diagnosed as herpes simplex or varicella zoster infection (see References: Byington 2008).

Clinical Features of Glandular and Ulceroglandular Tularemia
Feature	Characteristics
Incubation period	3-5 days (range, 1-14 days)
Presenting features^a	—Local painful cutaneous lesion at site of inoculation (papule that ulcerates within a few days) in ulceroglandular form; no cutaneous lesion in glandular form —Tender regional lymphadenopathy —Fever —Constitutional symptoms (chills, malaise, myalgias, arthralgias, headache, anorexia) —Other skin lesions may be noted (erythema nodosum; erythema multiforme–like exanthem on hands, arms, or legs; maculopapular rash; acneiform lesions; urticaria^b) —Clinical features for 39 patients identified during outbreak of predominantly ulceroglandular tularemia associated with exposure to muskrats in Vermont^c: ~Fever (97%) ~Cutaneous ulcers (74%) ~Axillary adenopathy (67%) ~Chills (59%) ~Myalgias (56%) ~Malaise (51%) ~Diaphoresis (28%) ~Epitrochlear adenopathy (25%) ~Nausea and vomiting (8%) ~Pleuritic chest pain (5%) ~Cough (5%) ~Preauricular adenopathy (2%)
Laboratory features	—In one series of 88 patients with tularemia, admission WBCs ranged from 5,000 to 22,000/mm³ (median, 10,400/mm³)^d; differential usually normal early in clinical course —Elevated hepatic enzymes and bilirubin may occur^d
Complications	—Suppuration of involved lymph nodes —Secondary pneumonia (31% of patients with ulceroglandular disease in one case series^dand 17% of patients with ulceroglandular or glandular disease in another^e) —Involvement of other organs (via hematogenous spread) —Sepsis syndrome —Illness may be debilitating, with full recovery taking several months —Lymphadenopathy may persist for months^e
Case-fatality rate	—4.4% of 181 patients with ulceroglandular tularemia and 4.3% of 23 patients with glandular tularemia among case series of 225 patients reported from pre-antibiotic era^f —1.6% (2 of 123 patients with ulceroglandular or glandular tularemia) in case series of 165 treated cases occurring in Oklahoma 1979-1985^g —Fatalities usually associated with type A subspecies; type B subspecies less virulent
Abbreviations: WBC, white blood count. ^aSee References: Cross 2000, Dennis 2001, Evans 1985, Penn 2010, Sanders 1968. ^bSee References: Christenson 1984, Cross 2000, Dahlstrand 1971, Evans 1985. ^cSee References: Young 1969. ^dSee References: Evans 1985. ^eSee References: Sanders 1968. ^fSee References: Pullen 1945. ^gSee References: Rhorbach 1991.

Clinical Features of Pneumonic Tularemia^a
Feature	Characteristics
Incubation period	3-5 days (range, 1-14 days)
Presenting features^b	—Patients often present with community-acquired atypical pneumonia nonresponsive to conventional antibiotic therapy —Predominant symptoms include abrupt onset of fever, nonproductive cough, myalgias (particularly low back) —Nausea, vomiting, diarrhea may occur —Illness may be rapidly progressive and severe or may be indolent with progressive weakness and weight loss over several weeks to months —Skin lesions may be noted (erythema nodosum; erythema multiforme–like exanthem on hands, arms, or legs; maculopapular rash; acneiform lesions; urticaria) —Presenting features for 53 Finnish patients with inhalational exposure^c: ~Fever (100%) ~Headache, myalgias, arthralgias ("most") ~Dry cough (45%) ~Retrosternal discomfort, pleural pain, or dyspnea (45%) ~Sore throat (23%) ~Hemoptysis (2%)
Laboratory features	—Radiographic findings for 50 tularemia patients with pleuropulmonary involvement^d: ~Patchy subsegmental air space opacities (74%; unilateral in 54% overall) ~Hilar adenopathy (32%) ~Pleural effusion (30%; unilateral in 20% overall) ~Lobar or segmental opacities (18%; all unilateral) ~Cavitation (16%) ~Oval opacities (8%) ~Cardiomegaly with pulmonary edema pattern (6%; caused by pericarditis in one case) ~Apical infiltrate (4%) ~Empyema and bronchopleural fistula (4%) ~Mediastinal mass (2%; caused by hilar adenopathy) ~Miliary pattern (2%) —In one series of 88 patients with tularemia, admission WBCs ranged from 5,000 to 22,000/mm³ (median, 10,400/mm³)^e; differential usually normal early in clinical course —Elevated hepatic enzymes and bilirubin may occur^e —Sputum Gram stain often not helpful in making diagnosis
Complications	—Lung abscesses or cavitary lesions —Adult respiratory distress syndrome^f —Fibrosis and calcifications in affected lung areas or pleura as illness resolves —Granulomatous pleuritis (which may resemble tuberculosis)^g —Empyema with bronchopleural fistula —Involvement of other organs through hematogenous spread —Sepsis syndrome —Meningitis —Pericarditis^d,e —Illness may be debilitating, with full recovery taking several months; relapses have been reported with use of broad-spectrum antibiotics^h
Case-fatality rate	—Fatalities rare with appropriate antibiotic therapy (reported as 2.3% in one case series of 88 patients with tularemia, about half of whom had pulmonary involvement; both deaths occurred in patients with pneumonia^e) —Fatalities usually associated with type A subspecies; type B subspecies less virulent
Abbreviations: WBC, white blood count. ^aPneumonic tularemia may result either from primary inhalational exposure or occur as a secondary process in other forms of tularemia. Similarly, inhalational exposure may cause primary pneumonic tularemia, oropharyngeal tularemia, or typhoidal tularemia without obvious pulmonary involvement. In the past, the term "typhoidal tularemia" was used to refer to infections caused by inhalational exposure, even if pneumonia was the primary manifestation. This has resulted in some confusion in the medical literature. Experts have suggested that the term "typhoidal tularemia" not be used in the context of inhalational exposure but rather be used only to describe cases of tularemia with constitutional symptoms or sepsis syndrome and no obvious anatomic focus of disease (see References: Dennis 2001, Syrjala 1986). ^bSee References: Christenson 1984, Cross 2000, Dahlstrand 1971, Evans 1985, Fredricks 1996, Miller 1969, Roy 1989. ^cSee References: Syrjala 1985. ^dSee References: Rubin 1978. ^eSee References: Evans 1985. ^fSee References: Sunderrajan 1985. ^gSee References: Schmid 1983: Granulomatous pleuritis caused by Francisella tularensis: possible confusion with tuberculous pleuritis. ^hSee References: Overholt 1961.

Clinical Features of Oculoglandular Tularemia
Feature	Characteristics
Incubation period	3-5 days (range, 1-14 days)
Presenting features^a	—Multiple painful yellow conjunctival nodules —Conjunctival ulcers —Chemosis —Periorbital and facial edema around affected eye —Extremely tender regional adenopathy involving preauricular, submandibular, or cervical lymph nodes; edema around affected nodes may be present —Patients may present with Parinaud's syndrome (unilateral granulomatous conjunctivitis and enlarged preauricular lymph nodes)^b —Constitutional symptoms (fever, chills, malaise, anorexia) —History of minor eye trauma, swimming in potentially contaminated water (possibly a risk factor)^b, or tick exposure may be present with naturally acquired infection
Laboratory features	—Generally unremarkable —Gram stain of conjunctival scrapings may demonstrate organisms, although Gram stain often not helpful^b
Complications	—Suppuration of affected lymph nodes —Sepsis syndrome —Involvement of other organs (through hematogenous spread)
Case-fatality rate	—1 (14.3%) of 7 patients with oculoglandular tularemia among case series of 225 patients reported from pre-antibiotic era^c —Fatalities rare with appropriate antibiotic therapy
^aSee References: Cross 2000, Guerrant 1976, Halperin 1985, Penn 2010. ^bSee References: Halperin 1985. ^cSee References: Pullen 1945.

Clinical Features of Oropharyngeal Tularemia
Feature	Characteristics
Incubation period	3-5 days (range, 1-14 days)
Presenting features^a	—Fever —Constitutional symptoms (chills, malaise, myalgias, arthralgias) —Exudative pharyngitis or tonsillitis —Ulcerations of pharynx, tonsils, soft palate —Stomatitis (less common) —May see pharyngeal membrane suggestive of diphtheria (membrane associated with tularemia does not bleed if removed, unlike diphtheria, in which removal of membrane reveals bleeding submucosa) —Cervical or retropharyngeal adenopathy (cervical nodes tender to palpation) —Concomitant pneumonia often present —Patients may present with dental abscesses —Findings in 12 patients with pharyngeal involvement in case series of 88 patients^b: ~Erythema (50%) ~Petechiae or hemorrhage (25%) ~Exudate (17%) ~Ulcers (8%) —The most common symptoms among 145 patients in Turkey^c: ~Swelling of the neck (92%) ~Sore throat (92%) ~Fever (90%)
Laboratory features	—Generally unremarkable, although leukocytosis may be present —Among patients in Turkey, ESR was elevated in all, and 79% had an ESR exceeding 55 mm/hr^c
Complications	—Sepsis syndrome —Suppuration of involved lymph nodes —Involvement of other organs (via hematogenous spread) —Illness may be debilitating, with full recovery taking several months
Case-fatality rate	—Fatalities rare with appropriate antibiotic therapy —Fatalities usually associated with type A subspecies; type B subspecies less virulent
Abbreviation: ESR, erythrocyte sedimentation rate. ^aSee References: Luotonen 1986, Tunga 2007, Tyson 1976. ^bSee References: Evans 1985. ^cSee References: Meric 2008.

Clinical Features of Typhoidal Tularemia^a
Feature	Characteristics
Incubation period	3-5 days (range, 1-14 days)
Presenting features^b	—Fever —Constitutional symptoms (chills, malaise, weakness, myalgias, arthralgias) —Prostration —Dehydration —Gastrointestinal symptoms (watery, nonbloody diarrhea; vomiting; abdominal pain) —Skin lesions may be noted (erythema nodosum; erythema multiforme–like exanthem on hands, arms, or legs; maculopapular rash; acneiform lesions; urticaria)
Laboratory features	—In one series of 88 patients with tularemia, admission WBCs ranged from 5,000 to 22,000/mm³ (median, 10,400/mm³); differential usually normal^c —Elevated hepatic enzymes and bilirubin may occur^c —Microscopic pyuria may occur^c
Complications	—Secondary pneumonia (83% of patients with typhoidal disease in one case series^c and 50% in another^d) —Involvement of other organs via hematogenous spread (eg, meningitis,^e hepatitis and jaundice,^f splenic rupture, encephalitis, pericarditis,^c peritonitis, osteomyelitis) —Sepsis syndrome —Rhabdomyolysis^g —Renal failure^d —Illness may be debilitating, with full recovery taking several months; relapses have been reported with use of broad-spectrum antibiotics^h
Case-fatality rate	—50% in one series of 14 patients with typhoidal tularemia among case series of 225 patients reported from pre-antibiotic eraⁱ —6.6% (2 of 30 patients with typhoidal tularemia) in case series of 165 treated cases occurring in Oklahoma 1979-1985 ^j —Fatalities usually associated with type A subspecies; type B subspecies less virulent
^aIn the past, the term "typhoidal tularemia" was used to refer to infections caused by inhalational exposure, even if pneumonia was the primary manifestation. This has resulted in some confusion in the medical literature. Experts have suggested that the term "typhoidal tularemia" not be used in the context of inhalational exposure but rather be used only to describe cases of tularemia with constitutional symptoms or sepsis syndrome and no obvious anatomic focus of disease (see References: Dennis 2001, Syrjala 1986). ^bSee References: Christenson 1984, Cross 2000, Dahlstrand 1971, Dennis 2001, Evans 1985, Penn 2010, Sanders 1968. ^cSee References: Evans 1985. ^dSee References: Sanders 1968. ^eSee References: Lovell 1986, Stuart 1945. ^fSee References: Ortego 1986. ^gSee References: Klotz 1987, Penn 1987. ^hSee References: Overholt 1961. ⁱSee References: Pullen 1945. ^jSee References: Rohrbach 1991.

Pediatric Considerations

In general, clinical manifestations of tularemia are similar in children and adults. One report from Arkansas compared type of illness and clinical symptoms between children and adults with naturally occurring tularemia identified in 1983; findings are noted in the following table.

Comparison Between Cases of Tularemia in Children and Adults, Arkansas 1983

Type of Disease or Symptoms

Percentage of Children
(n = 28)

Percentage of Adults
(n = 43)

Type of Disease

Glandular

Ulceroglandular
Pneumonic
Oculoglandular

Oropharyngeal
Typhoidal
Unclassified

45
14
2

4
2
6

51
18
—
—
12
11

Symptoms

Lymphadenopathy
Fever
Ulcer/papule
Pharyngitis
Myalgias/arthralgias
Nausea/vomiting
Hepatosplenomegaly

Headache
Cough

Chills
Diarrhea
Conjunctivitis

96
87
45
43
39
35
35

9
9

—
4
4

65
21^a
51
—
2
19
—

5
5

5
5
—

^aAlthough this percentage was reported for fever among adults in this series of patients, fever generally is a hallmark finding for tularemia.

Adapted from Jacobs 1985 (see References).

Differential Diagnosis

Differential Diagnosis for Glandular Tularemia
Condition^a,b	Distinguishing Features
Bubonic plague (Yersinia pestis)	—Clinical course often fulminant —Systemic toxicity common
Cat-scratch disease (Bartonella henselae)	—History of contact with cats; usually history of cat scratch —Indolent clinical course; progresses over weeks —Primary lesion at site of scratch often present (small papule, vesicle)
Mycobacterial infection, including scrofula (Mycobacterium tuberculosis and other Mycobacterium species)	—With scrofula, adenitis occurs in cervical region —Lymph nodes generally painless and nontender —Infections with species other than M tuberculosis more likely to occur in immunocompromised patients
Sporotrichosis (Sporothrix schenckii)	—Lymph nodes generally painless and nontender —Systemic symptoms absent —Painless papulonodular cutaneous lesion usually present distal to involved lymph nodes; secondary cutaneous lesions may occur along lymphatic channels —Patients often have history of contact with soil, plants, or plant products (eg, sphagnum moss, thorned plants such as rose bushes)
Streptococcal or staphylococcal adenitis (Staphylococcus aureus, Streptococcus pyogenes)	—Site of initiating infection often present distal to involved nodes (ie, pustule, infected traumatic lesion) —Involved nodes more likely to be fluctuant
Chancroid (Haemophilus ducreyi)	—Adenitis occurs in inguinal region only —Ulcerative lesion present —History of sexual exposure or activity
Lymphogranuloma venereum (Chlamydia trachomatis)	—Adenitis occurs in inguinal region only —Suppuration, fistula tracts common —Although lymph nodes may be somewhat tender, exquisite tenderness usually absent — History of sexual exposure 10-30 days prior
Primary genital herpes	—Herpes lesions in genital area —Adenitis in inguinal region only —History of sexual exposure or activity
Secondary syphilis (Treponema pallidum)	—Enlarged lymph nodes in inguinal region only —Lymph nodes generally painless and nontender —History of sexual exposure or activity
^aSee References: Butler 1979, Cross 2000, Penn 2010. ^bInfectious causes of generalized lymphadenopathy (eg, cytomegalovirus infection, toxoplasmosis, mononucleosis, lymphoma) also may be considered, depending on the clinical presentation.

Differential Diagnosis for Ulceroglandular Tularemia
Condition	Distinguishing Features
Anthrax (Bacillus anthracis)	—Painless ulcer that develops into black eschar over several days —Extensive non-pitting edema around lesion may occur
Orf (orf virus, a parapox virus)	—Occurs in farm workers —Characterized by pustule that progresses to weeping nodule —Regional adenitis may occur, but not common
Pasteurella infections (Pasteurella multocida)	—History of dog or cat exposure (animal bite or licking of open wound) —Regional lymphadenopathy occurs in 30%-40% of cases
Primary syphilis (Treponema pallidum)	—Characterized by painless ulcer (chancre) in genital area —Lymph nodes generally painless and nontender
Rat-bite fever (Spirillum minus)^a	—Infection caused by S minus occurs in Asia —Maculopapular rash over palms, soles, and extremities 2-4 days after onset of fever
Rickettsialpox (Rickettsia akari)	—Initial presentation involves painless papule which forms black eschar —Generalized maculopapular rash appears 2-3 days later —Regional lymphadenopathy usually present but nontender
Scrub typhus (Orientia tsutsugamushi; formerly Rickettsia tsutsugamushi)	—Zoonotic infection from chigger bites —Occurs in endemic areas (Asia and Western Pacific) —Often associated with a generalized maculopapular rash
Staphylococcal or streptococcal cellulitis (Staphylococcus aureus, Streptococcus pyogenes)	—May be history of trauma or preexisting lesion at site of infection
^aRat-bite fever caused by Streptobacillus moniliformis (type found in North America and Europe) generally does not result in ulceration at site of bite, is not associated with regional lymphadenopathy, and therefore is not considered in differential diagnosis of ulceroglandular tularemia.

Differential Diagnosis for Pneumonic Tularemia
Condition^a,b	Distinguishing Features
Community-acquired bacterial pneumonia —Mycoplasmal pneumonia (Mycoplasma pneumoniae) —Pneumonia caused by Chlamydia pneumoniae —Legionnaires' disease (Legionella pneumophila or other Legionella species) —Psittacosis (Chlamydia psittaci) —Other bacterial agents (eg, Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, Klebsiella pneumoniae, Moraxella catarrhalis)	—Legionellosis and many other bacterial agents (S aureus, S pneumoniae, H influenzae, K pneumoniae, M catarrhalis) usually occur in persons with underlying pulmonary or other disease or in elderly —Bird exposure with psittacosis —Community outbreaks caused by other etiologic agents less likely to suggest point-source outbreak (as would be seen with intentional release of Francisella tularensis) —Outbreaks of S pneumoniae usually institutional —Community outbreaks of legionnaires' disease often involve exposure to cooling towers —Gram stain of sputum may be useful in distinguishing agents
Inhalational anthrax (Bacillus anthracis)	—Widened mediastinum and pleural effusions seen on CXR or chest CT —Not true pneumonia; minimal sputum production —Severe and rapidly progressive course; often fulminant and fatal
Pneumonic plague (Yersinia pestis)	—Hemoptysis commonly occurs —Consolidation often noted on CXR early in clinical course (radiographic evidence of pneumonia in patients with tularemia generally not as pronounced early in clinical course) —Severe and rapidly progressive course; often fulminant and fatal
Q fever (Coxiella burnetii)	—Exposure to infected parturient cats, cattle, sheep, goats —May be difficult to distinguish clinically from pneumonic tularemia
Tuberculosis (Mycobacterium tuberculosis)	—More common among elderly or among persons who have lived in tuberculosis-endemic countries (ie, developing world, countries of the former Soviet Union)
Viral pneumonia —Influenza —Hantavirus —RSV —CMV	—Influenza generally seasonal (October-March in United States) or involves history of recent cruise ship travel or travel to tropics —Exposure to excrement (urine and feces) of mice with hantavirus —RSV usually occurs in children (although may be cause of pneumonia in elderly); tends to be seasonal (winter/spring) —CMV usually occurs in immunocompromised patients
Abbreviations: CMV, cytomegalovirus; CT, computed tomography; CXR, chest x-ray; RSV, respiratory syncytial virus. ^aOther causes of pneumonia (eg, fungal infections) also may be considered, depending on the clinical presentation and setting. ^bSee References: Butler 1979, Cross 2000, Penn 2010.

Differential Diagnosis for Oculoglandular Tularemia
Condition^a,b	Distinguishing Features
Adenoviral infection (adenovirus)	—Generally not associated with regional lymphadenopathy —Systemic symptoms absent —Commonly hemorrhagic
Cat-scratch disease (Bartonella henselae)	—Watery discharge, granulomatous conjunctival nodule, chemosis —Lymph nodes nontender —Mild systemic toxicity may be present but usually less severe than that seen with tularemia
Coccidioidomycosis (Coccidioides immitis)	—Granulomatous conjunctival nodule with small areas of necrosis —Lymph nodes may be tender and some systemic toxicity may be present
Herpes infection (herpes simplex virus)	—Causes characteristic dendritic keratitis in addition to conjunctivitis
Pyogenic bacterial infections	—Mild cases not associated with regional lymphadenopathy —Systemic symptoms usually absent
Sporotrichosis (Sporothrix schenckii)	—Firm chancre in skin of eyelid, yellow conjunctival nodules, subcutaneous nodules along lymphatics —Lymph nodes nontender —Systemic symptoms absent
Syphilis (Treponema pallidum)	—Conjunctival ulcer with indurated margin and gray base —Lymph nodes nontender —Systemic symptoms absent
Tuberculosis (Mycobacterium tuberculosis)	—Small conjunctival ulcer embedded in nodule —Lymph nodes nontender —Systemic symptoms generally absent
^aSee References: Halperin 1985. ^bOther rare causes of oculoglandular syndrome include actinomycosis, blastomycosis, yersiniosis, listeriosis, mumps, lymphogranuloma venereum, and chancroid.

Differential Diagnosis for Oropharyngeal Tularemia
Condition^a	Distinguishing Features
Streptococcal pharyngitis (Streptococcus pyogenes)	—Responds to penicillin therapy
Infectious mononucleosis (Epstein-Barr virus)	—Most common in young adults —Splenomegaly commonly occurs
Adenoviral infection (adenovirus)	—Occurs mostly in children and young adults —Often associated with rhinorrhea
Diphtheria (Corynebacterium diphtheriae)	—Primarily occurs in nonimmune children under 15 yr of age —Removal of pharyngeal membrane often causes bleeding of submucosa (unlike tularemia)
^aSee References: Cross 2000, Penn 2010, Tyson 1976.

Differential Diagnosis for Typhoidal Tularemia
Condition	Distinguishing Features
Typhoidal tularemia without sepsis^a
Brucellosis (Brucella abortus and other Brucella species)	—Usually history of contact with tissues, blood, aborted fetuses of infected animals (cattle, swine, goats, sheep) —Occupational disease
Disseminated mycobacterial or fungal infection	—Underlying illness usually present
Endocarditis	—Features of endocarditis (eg, cardiac murmur, embolic phenomenon) often present —Risk factors may be present (underlying cardiac abnormality, prosthetic valve, injecting drug use)
Leptospirosis (Leptospira interrogans)	—History of exposure to infected animals or to water or soil contaminated with urine from infected animals —Characteristic features (in addition to acute onset of febrile illness) include conjunctival suffusion, severe myalgias, and pretibial maculopapular eruption
Pontiac fever (Legionella pneumophila)	—Often mild clinical illness; does not require antibiotic therapy
Malaria (Plasmodium species)	—History of travel to malaria-endemic area is typical —Cyclic fevers (every 48 hr for P vivax or P ovale; every 72 hr for P malariae) or continuous fever with intermittent spikes (most common pattern for P falciparum) —Parasites may be seen on microscopic examination of thick or thin smears
Q fever (Coxiella burnetii)	—Exposure to infected parturient cats, cattle, sheep, goats
Typhoid fever (Salmonella typhi)	—Symptoms of enterocolitis and abdominal pain may be more prominent with typhoid fever than with typhoidal tularemia —Bloody diarrhea may be present (not usually seen with tularemia)
Typhoidal tularemia with sepsis
Meningococcemia (Neisseria meningitidis)	—Rapid progression to shock and often death
Septicemic plague (Yersinia pestis)	—Often secondary to bubonic plague (characteristic bubo present in groin, axilla, or cervical region) —Fulminant, often fatal course
Septicemia caused by other gram-negative bacteria	—Underlying illness usually present —Fulminant course
Staphylococcal or streptococcal TSS (Staphylococcus aureus, Streptococcus pyogenes)	—Streptococcal TSS may be associated with necrotizing fasciitis —Staphylococcal TSS often associated with characteristic epidemiologic features (eg, tampon use in menstruating women, antecedent trauma)
Abbreviation: TSS, toxic shock syndrome. ^aSee References: Cross 2000, Penn 2010.

Clinical Laboratory Testing

Specimen Collection and Transport

Because F tularensis may grow in conventional culture media, thus posing danger to laboratory personnel, the ordering physician should immediately notify the laboratory if the diagnosis of tularemia is suspected. Delay in such notification can lead to unnecessary exposure of laboratory personnel (see References: Shapiro 2002).
Advance notification also may increase the likelihood of detection, as use of special culture media can improve recovery of the organism.

Collection and Transport of Clinical Specimens for Diagnosis of Tularemia
Site	Specimen Collection and Transport^a,b
Blood	—Collect volume and number of sets per established laboratory protocol. —Transport to laboratory at room temperature. —In laboratory, maintain at room temperature until incubation; do not refrigerate. —Follow established blood culture protocols. —Collect acute-phase serum during first week of illness, and store at 4^oC until tularemia can be ruled out. —If tularemia is not ruled out, collect convalescent-phase serum 14 days or more after illness onset (antibodies appear in most patients by 2 wk after onset, and levels peak at 4-5 wk). —Ship at 4^oC.
Ulcer, other tissue specimens	—Collect biopsy (preferred), scraping, swab, or aspirate of ulcer, lymph node, or other involved tissue. —Biopsy or scraping: ~Place biopsy tissue or scraping in sterile container. ~Add several drops of sterile normal saline to small tissue samples to keep specimen moist. ~Transport at room temperature for immediate processing. ~Refrigerate (4^oC) if processing delayed. —Aspirate: ~Transport at room or refrigerator (4^oC) temperature. ~Refrigerate (4^oC) if processing delayed. —Swab: ~Obtain firm sample of advancing margin of lesion. ~If using swab transport carrier, reinsert swab into transport package and moisten swab fabric with transport medium inside packet. ~Transport at room or refrigerator (4^oC) temperature. ~Refrigerate (4^oC) if processing delayed.
Other	—Respiratory specimens (pleural fluid, sputum), gastric washings, or corneal scraping (oculoglandular tularemia) can be sent for culture. —Transport at room or refrigerator (4^oC) temperature. —Refrigerate (4^oC) if processing delayed.
Environmental samples	—Environmental samples should only be collected in context of epidemiologic investigation. —Optimal collection samples and methods have not been determined.^c
^aSpecimens for culture should be taken before administration of antimicrobial therapy. ^bSee References: CDC/ASM/APHL 2001, Cross 2000, Penn 2010, Wong 1999. ^cIn a study of field-necropsied prairie dogs, Francisella tularensis was recovered from 11.1% of infected tissue using Cary-Blair transport medium at 4^oC and from 88.8% of tissue frozen on site at -20^oC (see References: Petersen 2004).

Guidelines have been published for packing and shipping of infectious substances, diagnostic specimens, and biological agents from suspected bioterrorism (see References: ASM 2008). F tularensis is classified under World Health Organization (WHO) infectious agent risk group 4. Isolates that are reasonably suspected to contain F tularensis must be transported as "infectious substances." International Air Transport Association (IATA) rules require training of all individuals involved in the transport of dangerous goods, including infectious substances. Once F tularensis is identified, isolates and specimens are regulated as select agents and are subject to additional transport requirements (see below). Chain-of-custody should be documented for material that may constitute evidence of criminal activity.

Laboratory Biosafety and Biosecurity Information

F tularensis remains an important potential cause of laboratory-acquired infections (see References: Pike 1976), owing in part to the very low infectious dose (ie, as low as 10 organisms by aerosol exposure or inoculation). Tularemia was the most common laboratory-acquired infection during the 25 years of the US Biological Warfare Program (see References: Rusnak 2007). Most recently, in November 2009, a researcher at the US Army Medical Research Institute of Infectious Diseases (USAMRIID) in Fort Detrick, Maryland, contracted tularemia while working on a vaccine for the disease (see References: Eckstein 2009).
The agent may be present in virtually any human specimen, tissues from infected animals, and fluids from infected arthropods.
Recognized laboratory hazards include the following (see References: CDC 2007):

Exposure to infectious aerosols or droplets through manipulation of cultures
Direct contact of skin or mucous membranes with infectious materials
Accidental parenteral inoculation
Accidental ingestion

Manipulation of cultures presents the greatest risk to laboratory workers. In Missouri from 2000 through 2007, specimens for 33 (85%) of 39 culture-confirmed cases were received by the laboratory without any indication of suspicion of a tularemia diagnosis. Laboratory workers should take appropriate precautions when handling culture specimens from tularemia-endemic regions (see References: CDC 2009).
Recommended laboratory precautions include the following (see References: CDC 2007):

Biosafety level 2 (BSL-2) practices, containment equipment, and facilities (which are present in most hospital clinical laboratories) are recommended for activities with clinical materials of human or animal origin containing or potentially containing F tularensis.
Biosafety level 3 (BSL-3) practices, containment equipment, and facilities are recommended for all manipulations of cultures and for experimental animal studies.

Vaccination is not recommended for Laboratory Response Network (LRN) sentinel laboratory personnel (see References: CDC: Emergency Preparedness and Response > Preparedness for All Hazards > Labs > Biosafety > Vaccines).
Laboratory safety practices associated with F tularensis and other potential agents of bioterrorism have been reviewed elsewhere (see References: Sewell 2003).
F tularensis is classified as a select agent and therefore is regulated under 42 CFR part 73 (Possession, Use, and Transfer of Select Agents and Toxins), which was published as a Final Rule in the Federal Register in 2005 (see References: HHS 2005). As specified in the Public Health Security and Bioterrorism Preparedness and Response Act of 2002, 42 CFR part 73 provides requirements for laboratories that handle select agents (including registration, security risk assessments, safety plans, security plans, emergency response plans, training, transfers, record keeping, inspections, and notifications). Select agents are biological agents designated by the US government to be major threats to public health and safety. A current list of select agents is published on the Centers for Disease Control and Prevention (CDC) Web site under information about the Select Agent Program (see References: CDC/APHIS 2008). In addition, the CDC has published additional guidelines for enhancing laboratory security for laboratories working with select agents (see References: CDC 2002: Laboratory security and emergency response guidance for laboratories working with select agents).
One report demonstrated that delay in appropriate identification of F tularensis led to the potential exposure of 12 microbiology laboratory workers (11 of whom received prophylactic antibiotics; the other was pregnant and was placed on fever watch) (see References: Shapiro 2002). The authors suggested that when an organism is initially recognized as having the following properties, further work with the organism should be performed within a biological safety cabinet by a technologist wearing gloves and a gown until the organism is further identified:

Small, poorly staining, gram-negative rods seen mostly as single cells that yield mostly pinpoint colonies on chocolate agar and often sheep agar at 48 hours
No growth on MacConkey or eosin-methylene blue agar
Oxidase-negative with a negative or weakly positive catalase test
A negative satellite test
Isolates that grow only on buffered chocolate yeast extract and chocolate agar

The Laboratory Response Network (LRN)

The LRN is a national network of approximately 150 laboratories. The network includes the following types of labs: federal, state and local public health, military, food testing, environmental, veterinary, and international (located in Canada, the United Kingdom, and Australia) (see References: CDC: Facts about the Laboratory Response Network, CDC: The Laboratory Response Network).

The LRN structure for bioterrorism designates laboratories as either national, reference, or sentinel. Designation depends on the types of tests a laboratory can perform and how it handles infectious agents to protect workers and the public.

National laboratories have unique resources to handle highly infectious agents and the ability to identify specific agent strains.
Reference laboratories, sometimes referred to as "confirmatory reference," can perform tests to detect and confirm the presence of a threat agent. These laboratories ensure a timely local response in the event of a terrorist incident. Rather than having to rely on confirmation from laboratories at the CDC, reference laboratories are capable of producing conclusive results; this allows local authorities to respond quickly to emergencies. These are mostly state or local public health laboratories with BSL-3 containment facilities that have been given access to nonpublic testing protocols and reagents.
Sentinel laboratories represent the thousands of hospital-based labs that are on the front lines. Sentinel laboratories have direct contact with patients. In an unannounced or covert terrorist attack, patients provide specimens during routine patient care. Sentinel laboratories could be the first facilities to spot a suspicious specimen. A sentinel laboratory’s responsibility is to refer a suspicious sample to the right reference laboratory. These laboratories generally have at least BSL-2 containment.

Standard Tests for Detection of F tularensis

No commercial "kit" system is available for F tularensis, but a number of methods are available for diagnostic purposes (see References: Shapiro 2009). Tularemia diagnosis traditionally has been based on serology, with a definitive diagnostic criterion of a fourfold or greater rise in antibody titers between acute-phase and convalescent-phase sera. As with other infections, there are limitations to serologic diagnosis of tularemia, including difficulty in obtaining acute and convalescent specimens (especially with the nonspecific clinical presentation), cross-reactivity with other bacteria, blunting of the serologic response by antiobiotic therapy, and long-term persistence of antibody levels (see References: Hepburn 2007).

Direct stains for bacterial micromorphology

LRN-approved Gram stain (see References: CDC/ASM/APHL 2001, Cross 2000, Sneath 1986, Wong 1999):

Tiny, faintly staining, pleomorphic gram-negative rods (0.2-0.5 mcm X 0.7-1.0 mcm) are noted; cells are smaller than those of Haemophilus species.
The sensitivity of Gram stain is limited in samples that contain background material (eg, blood, sputum, biopsy tissue).
Organisms are nonsporulating.

Tissue stains: F tularensis may be visualized in fixed tissues or impression smears with May-Grunwald-Giemsa, phenol thionin, or modified Dieterle spirochete stain (see References: Gallivan 1980, OIE 2004).

Bacteriologic culture

Approved for LRN sentinel laboratories.
Standard procedures for culture are as follows (see References: CDC/ASM/APHL 2001, Wong 1999):

Culture setup procedure: Use standard routine protocols for specimen type.
In addition, add cysteine-supplemented media, such as chocolate agar (CA) with IsoVitaleX or buffered charcoal yeast extract agar (BCYE).
Cysteine heart agar supplemented with 9% heated sheep red blood cells (CHAB) was mentioned in earlier CDC protocols but was excluded from current level A protocols (see References: CDC/ASM/APHL 2001).
Selective, enriched media such as Thayer-Martin (TM) media improves isolation from contaminated samples.
Organisms do not grow on MacConkey or eosin-methylene blue (EMB) agars; they may grow initially on sheep blood agar (SBA) but not on subculture.
Tape plates shut if F tularensis is suspected.
Optimal growth conditions include 35^oC to 37^oC at ambient atmosphere in contrast to Y pestis, which grows faster at 28^oC. Use of 5% CO₂ is acceptable.
Incubation time generally is 5 days (7 days if the patient has been treated with a bacteriostatic antibiotic).
Colony morphology at 24 hours is too small to be seen.
At 48 hours, colonies are 1 to 2 mm in diameter, white to gray to bluish-gray, opaque, flat, and smooth, with an entire edge and shiny surface.
F tularensis typically grows slowly in broth media, requiring a minimum of 10 days of incubation without shaking for detection (see References: Ellis 2002).

Colonies on chocolate agar, 72 hours.

From CDC/ASM/APHL 2001 [see References]).

Biochemical screening

Approved for LRN sentinel laboratories (see References: CDC/ASM/APHL 2001).
Isolates identified as F tularensis (or isolates that cannot be ruled out as F tularensis) should be forwarded to an LRN reference laboratory for confirmatory testing.
Biochemical screening tests:

Oxidase-negative
Weakly catalase-positive (although may be negative)
Urease-negative
Nitrate-negative
Nonmotile
Beta-lactamase-positive
Satellite or XV test-negative (unlike Haemophilus species)

Attempts at identification of organisms with the above microscopic, colony, and biochemical characteristics should not be attempted. [Note: This is extremely important because of the potential for generation of infectious aerosols and because of the potential for misidentification.]
Commercial identification tests:

The Vitek NHI card may identify F tularensis as Actinobacillus actinomycetemcomitans with as high as a 99% confidence level.

Other considerations for LRN sentinel laboratories:

If tularemia is initially suspected, the sentinel laboratory should consult with the state public health laboratory director (or designate) prior to or concurrent with testing.
The laboratory should communicate immediately with the state public health laboratory director (or designate), the infection control department at the hospital, and the attending physician if F tularensis cannot be ruled out.
If a bioterrorist release is suspected, the original specimens should be preserved pursuant to a potential criminal investigation. In such situations, the state public health department, in conjunction with the Federal Bureau of Investigation (FBI) or local law enforcement as necessary, will arrange for transport of specimens and/or isolates to a higher-level LRN laboratory.

Additional Tests for Detection, Confirmation, and Characterization of F tularensis

The CDC has approved the following tests for detection of F tularensis at various levels of the LRN.

Selected tests approved for LRN reference laboratories

Direct fluorescent antibody (DFA) stain
Slide agglutination
Antimicrobial susceptibility testing
Biochemical identification/characterization
Serology (antibody detection)
Environmental specimen evaluation
PCR
Mouse inoculation
Cellular fatty acid analysis
Molecular-based subtyping tests

Selected tests approved for LRN national laboratories

Immunohistochemistry (IHC)

Other described tests for F tularensis

A wide variety of other tests for F tularensis detection have been developed. These include new serologic tests, PCR tests (including multiplex PCR), 16S rRNA sequencing, time-resolved fluorometry (TRF) assay, and molecular subtyping.

Hand-held immunochromatographic assays have been described and are commercially available, but detection limits appear to be higher than PCR or competitive enzyme-linked immunoabsorbent assay (cELISA) (see References: Alexeter Technologies, Grunow 2000, New Horizons Diagnostics Inc).

Antimicrobial susceptibility studies

Two studies have examined antimicrobial susceptibilities of F tularensis strains to various antibiotics. Data from these studies are shown in the table below. The studies were conducted prior to the development of standard methods and interpretive criteria and should be used for comparison purposes only. Only LRN laboratories classified as reference or national should perform susceptibility testing.

The major conclusions from each of the two studies are as follows:

Ikaheimo 2000 (see References), using 38 human and animal F tularensis subsp holarctica strains; tests conducted using Etest (Biodisk; Solna,Sweden):

All strains were susceptible to the antibiotics traditionally used to treat tularemia (streptomycin, tetracycline, chloramphenicol) as well as other aminoglycosides (tobramycin, gentamicin) and fluoroquinolones (ciprofloxacin, levofloxacin, grepafloxacin, trovafloxacin).
All strains were resistant to beta-lactam antibiotics and azithromycin.
The strains used in this study were F tularensis subsp holarctica (type B), which may not reflect susceptibility patterns of F tularensis subsp tularensis (type A), the more likely agent in a bioterrorism event.

Baker 1985 (see References), using 13 "glycerol-positive" and 2 "glycerol-negative" strains of F tularensis; tests conducted using broth dilution:

Aminoglycosides (streptomycin, gentamicin, tobramycin), tetracycline, chloramphenicol, and erythromycin were effective in vitro.
The authors concluded that several cephalosporins (ceftazidime, cefotaxime, ceftriaxone) were effective in vitro, while other beta-lactam antibiotics were not. They acknowledged, however, that all strains produced beta-lactamase.

MICs of Various Antibiotics for Francisella tularensis Isolates as Identified in Two Studies
	Ikaheimo 2000^a		Baker 1985^b
Antibiotic	MIC range^c	MIC₉₀^c	MIC range	MIC₉₀
Ampicillin	—	—	>8.0	>8.0
Azithromycin	>256	>256	—	—
Cefotaxime	—	—	<0.12-4.0	4.0
Cefpirome	>256	>256	—	—
Ceftazidime	>256	>256	<0.5-1.0	<0.5
Ceftriaxone	>32	>32	0.5-16.0	8.0
Chloramphenicol	0.125-0.5	0.38	<0.25-4.0	1.0
Ciprofloxacin	0.008-0.023	0.016	—	—
Clindamycin	—	—	1.0->2.0	>2.0
Erythromycin	—	—	0.5-2.0	2.0
Gentamicin	0.38-1.5	1.0	0.25-2.0	2.0
Grepafloxacin	0.016-0.047	0.047	—	—
Imipenem	>32	>32	—	—
Levofloxacin	0.008-0.023	0.016	—	—
Meropenem	>32	>32	—	—
Penicillin	—	—	4.0->8.0	>8.0
Piperacillin/tazobactam	>256	>256	—	—
Piperacillin	—	—	<0.5->64.0	64.0
Rifampin	0.094-0.38	0.25	<0.03-1.0	1.0
Streptomycin	0.25-4.0	4.0	<0.5-4.0	4.0
Tetracycline	0.094-0.5	0.38	<0.25-2.0	2.0
Tobramycin	0.5-2.0	1.5	<0.12-4.0	2.0
Trovafloxacin	0.012-0.047	0.032	—	—
Abbreviations: MIC, minimal inhibitory concentration; MIC₉₀, minimal inhibitory concentration for 90% of isolates tested. ^aHuman and animal type B isolates (geographic origins unspecified) (see References: Ikaheimo 2000). ^bHuman strains from southeastern and southwestern United States (subspecies unspecified) (see References: Baker 1985). ^cValues in mcg/mL.

Additional antimicrobial susceptibility studies include the following:

A study of eight isolates of F tularensis subsp tularensis (type A, the type most likely to be involved in a bioterrorism event) from the United States found them all to be highly susceptible to fluoroquinolones at 0.125 mcg/mL or less (see References: Johansson 2002).
Resistance of F tularensis to chloramphenicol and tetracycline has been experimentally created in the laboratory by the use of transformed plasmids (see References: Pavlov 1996) .
In Austria, F tularensis subsp holarctica biovar II strains from 47 hares and three humans were found to be susceptible by Etest to tetracyclines, aminoglycosides, quinolones, chloramphenicol, and rifampicin. Isolates were generally resistant to macrolides, penicillins, azetreonam, cephalosporins, and carbapenems (see References: Tomaso 2005).
The Clinical and Laboratory Standards Institute recently provided a susceptibility testing method with breakpoints. In total, they tested 169 isolates (92 type A, 77 type B) against seven antimicrobial agents (streptomycin, gentamicin, tetracycline, doxycycline, ciprofloxacin, levofloxacin, and chloramphenicol) used for treating tularemia. The minimum inhibitory concentrations (MICs) for all of the isolates were within the susceptible range. All isolates had MICs for erythromycin between 0.5 and 4 mcg/mL, in contrast to greater than 256 mcg/mL for the common laboratory live vaccine strain (LVS) (see References: Urich 2008).

Treatment, Postexposure Prophylaxis, and Vaccines

Treatment

Available data support the following statements about treatment of tularemia:

Streptomycin and gentamicin have been shown to be effective and are considered the first-line therapies (see References: AAP 2006, Enderlin 1994, Evans 1985, Hassoun 2006, Mason 1980).
Ciprofloxacin and other fluoroquinolone antibiotics have been used effectively to treat tularemia, although experience with these medications is somewhat limited to date (see References: Johansson 2000, Limaye 1999). In one outbreak, ciprofloxacin showed a lower treatment failure rate than streptomycin or doxycycline (see References: Perez-Castrillon 2001).
Tetracycline and chloramphenicol can be used to treat tularemia; however, because these drugs are bacteriostatic, relapses occur more often than with use of aminoglycosides (see References: Evans 1985, Overholt 1961).

The Working Group on Civilian Biodefense has made the following recommendations for treatment of tularemia during a bioterrorist attack (see References: Dennis 2001):

In a contained casualty setting where the medical care delivery system can effectively manage the number of patients, parenteral antibiotics should be administered to all patients whenever possible, according to the table below.
In a mass casualty setting where the medical care delivery system is not able to meet the demands for patient care, use of oral antibiotics may be necessary. In such a situation, the medications listed below in the table on antibiotic postexposure prophylaxis should be used and therapy should be continued for 14 days.
Supportive care of patients also is critical, including fluid management and hemodynamic monitoring as indicated. Some patients would require intensive care with respiratory support owing to complications of gram-negative sepsis (eg, shock, adult respiratory distress syndrome, multisystem failure, disseminated intravascular coagulation).
Bioterrorist use of an F tularensis strain resistant to conventional antibiotic therapy is of concern and should be considered, particularly if patients deteriorate despite early initiation of antibiotic therapy.

Recommendations for Treatment of Tularemia During a Bioterrorism Event
Choices by Patient Category	Therapy Recommendations^a,b
Adults: Preferred choices	Streptomycin: 1 g IM twice daily for 10 days^c,d,e or Gentamicin: 5 mg/km IM or IV once daily for 10 days^c,e
Adults: Alternative choices	Doxycycline: 100 mg IV twice daily for 14-21 days^e or Chloramphenicol: 15 mg/kg IV 4 times daily for 14-21 days^f or Ciprofloxacin: 400 mg IV twice daily for 10 days^c
Children: Preferred choices	Streptomycin: 15 mg/kg IM twice daily (maximum daily dose, 2 g) for 10 days^c or Gentamicin: 2.5 mg/kg IM or IV 3 times daily for 10 days^c
Children: Alternative choices	Doxycycline: >45 kg: same as adult <45 kg: 2.2 mg/kg IV twice daily for 14-21 days or Ciprofloxacin: 15 mg/kg IV twice daily for 10 days (maximum daily dose, 1 g) or Chloramphenicol: 15 mg/kg IV 4 times daily for 14-21 days (maximum daily dose, 4 g)^f
Abbreviations: IM, intramuscularly; IV, intravenously. ^aIn the mass casualty setting where the medical care delivery system is not able to meet the demands for patient care, oral antibiotics may need to be substituted for intravenous antibiotics for treatment of patients with tularemia. In such a situation, the recommendations in the table below on postexposure prophylaxis should be followed for treatment. ^bThese treatment recommendations reflect those of the Working Group on Civilian Biodefense and may not necessarily be approved by the Food and Drug Administration. ^cAcceptable for pregnant women. ^dStreptomycin is not as acceptable as gentamicin for use in pregnant women because irreversible deafness in children exposed in utero has been reported with streptomycin use. ^eAminoglycosides must be adjusted according to renal function. ^fConcentration should be maintained between 5 and 20 mcg/mL; concentrations >25 mcg/mL can cause reversible bone marrow suppression. Adapted from Dennis 2001 (see References).

Some have suggested that doxycycline is a good first choice for treatment, because it has greater efficacy than ciprofloxacin, has less potential for development of resistance, and is less expensive. Patient relapse is possible with this drug, however (see References: Brouillard 2006, Tarnvik 2007).

A recent study of 145 patients with oropharyngeal tularemia showed that 55 (38%) of those treated experienced initial therapeutic failure (defined as persistence or recurrence of fever, persistence of constitutional symptoms, or increase in size or appearance of new lymphadenopathies). Those patients required a second course of antibiotics, usually using an alternative agent. Logistic regression analysis found that initial therapeutic failure was significantly associated with delay of treatment exceeding 14 days and was not associated with the type of antibiotic used initially (see References: Meric 2008).

According to the American Academy of Pediatrics (AAP), streptomycin, gentamicin, and amikacin are recommended for treatment of children (see References: AAP 2006). Other therapies cited by the AAP include tetracycline and chloramphenicol, although relapse rates are higher with these agents.

Ciprofloxacin has recently been shown to be an effective therapy for tularemia in children (see References: Johansson 2000, Johansson 2002). The drug has been approved only for specific indications in patients younger than 18 years old (see References: AAP 2006).

Postexposure Prophylaxis

The newer fluoroquinolones trovafloxacin and grepafloxacin were studied in mice challenged via the subcutaneous route with 1 x 10³ colony-forming units of F tularensis. Antibiotics were orally administered once a day, for 7 days, commencing at 24 and 48 hours postchallenge. Mice were observed for an additional 14 days. Trovafloxacin provided complete protection against experimental F tularensis whether administered at 24 or 48 hours following infection. Grepafloxacin had more limited therapeutic activity, with survival rates of 50% and 80% when treatment was initiated at 24 hours and 48 hours, respectively. No untreated control mice survived. Both of these antibiotics have since been withdrawn from the market; however, these data confirm the efficacy of newer generation fluoroquinolones for postexposure prophylaxis against tularemia. Furthermore, the data provide additional evidence of the likely therapeutic windows for the use of these antibiotics (see References: Kenny 2009).

One challenge study involving volunteer subjects demonstrated that antibiotic postexposure prophylaxis using tetracycline can prevent disease occurrence among exposed persons if given within 24 hours after challenge (see References: Sawyer 1966).

The Working Group on Civilian Biodefense has made the following recommendations for postexposure prophylaxis of inhalational tularemia during a bioterrorist attack (see References: Dennis 2001):

If the release of F tularensis becomes known before clinical cases occur (ie, during the incubation period), persons in the exposed population should be placed on prophylactic oral antibiotics (doxycycline or ciprofloxacin) for 14 days, according to the regimens outlined in the table below.
If the release is covert and does not become apparent until after clinical cases begin to occur, then potentially exposed persons should be placed on a fever watch. Any person in whom a fever or flulike illness develops should be evaluated and placed on appropriate antibiotic therapy (either parenteral [in the contained casualty setting] or oral [in the mass-casualty setting]) for treatment of presumptive tularemia.

Decision making around use of postexposure prophylaxis would likely be extremely difficult in situations involving a suspected bioterrorist attack. If an exposed population can be inferred with reasonable probability from the ongoing investigation, strong consideration should be given to providing postexposure prophylaxis, even after clinical cases begin to occur. As noted during the anthrax investigation on Capitol Hill in late 2001, patients initiating prophylaxis may later discontinue it if the investigation subsequently determines that they were not at risk. Careful proactive initiation of postexposure prophylaxis should not be underestimated for its medical, public health, psychological, and political merits in coping with a terrorist attack.

Recommendations for Antibiotic Postexposure Prophylaxis During an Outbreak of Tularemia Following a Bioterrorism Event^a
Patient Category	Therapy Recommendations^b
Adults (including pregnant women)	Doxycycline: 100 mg PO twice daily for 14 days^c or Ciprofloxacin: 500 mg PO twice daily for 14 days^c
Children	Doxycycline: >45 kg: same as adult <45 kg: 2.2 mg/kg PO twice daily for 14 days or Ciprofloxacin: 15 mg/kg PO twice daily for 14 days (maximum daily dose, 1 g)
Abbreviation: PO, orally. ^aIn the mass-casualty setting where the medical care delivery system is not able to meet the demands for patient care, oral antibiotics may need to be substituted for intravenous antibiotics for treatment of patients with tularemia. In such a situation, the recommendations in this table should be followed for treatment as well as for prophylaxis. ^bRecommendations were reached by consensus of the Working Group on Civilian Biodefense and may not necessarily be approved by the Food and Drug Administration. ^cAlthough fetal toxicity may occur with doxycycline use, the working group recommended doxycycline or ciprofloxacin for postexposure prophylaxis of pregnant women or for treatment of infection of pregnant women in the mass-casualty setting. Adapted from Dennis 2001 (see References).

Vaccines

No licensed vaccine against tularemia currently is available in the United States.
Until recently, a vaccine incorporating an attenuated, type B derivative LVS was used in the United States to protect laboratory workers at high risk for F tularensis exposure. The vaccine was available at USAMRIID as an investigational new drug, but it has since been withdrawn and is no longer being manufactured (see References: Rusnak 2007). An improved LVS preparation has been tested for preclinical safety, tolerability, and immunogenicity in rabbits and is currently being evaluated in human clinical studies (see References: Pasetti 2008).
Because the incubation period for tularemia is usually 3 to 5 days and immunity following vaccination takes about 2 weeks to develop, postexposure vaccination is not considered a viable public health strategy to prevent disease in the event of a mass exposure.
It is likely that future work to develop vaccines against F tularensis will focus on subunit vaccines and use of recombinant technology (see References: Jia 2009, Sjostedt 2003). However, developing a new, effective vaccine against F tularensis poses several challenges:

The immunodominant antigens have not been fully identified and characterized.
The virulence determinants are not well known.
Generation of both humoral and cellular immune responses appears to be necessary for protection against infection.

Hospital Infection Control (Including Autopsies and Burial)

Isolation Precautions

Person-to-person transmission of tularemia has not been documented; therefore, Standard Precautions are considered adequate for patients with tularemia. Standard Precautions include the following practices related to direct patient care (see References: CDC/HICPAC 2007):

Handwashing:

Wash hands after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn.
Wash hands immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patients or environments.

Gloves:

Wear gloves when touching blood, body fluids, secretions, excretions, and contaminated items; put on clean gloves just before touching mucous membranes and nonintact skin.
Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms.
Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another patient, and wash hands immediately to avoid transfer of microorganisms to other patients or environments.

Masks, eye protection, face shields:

Wear a mask (ie, standard surgical mask) and eye protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions.

Gowns:

Wear a gown to protect skin and prevent soiling of clothing during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions.
Select a gown that is appropriate for the activity and amount of fluid likely to be encountered.
Remove a soiled gown as promptly as possible and wash hands.

Patient-care equipment:

Handle used equipment soiled with blood, body fluids, secretions, or excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of microorganisms to other patients or environments.
Ensure that reusable equipment is not used for the care of another patient until it has been appropriately cleaned and reprocessed; single-use items should be appropriately discarded.

Decontamination

Commercially available bleach or a 1:10 dilution of household bleach and water is considered adequate for cleaning contaminated surfaces. After 10 minutes, a 70% solution of alcohol can be used to further clean the area and reduce the corrosive action of the bleach (see References: Dennis 2001).
Following direct exposure to powder or liquid aerosols containing F tularensis, body surfaces and clothing should be washed with soap and water.
Water contamination can be eradicated through standard chlorination. Chlorinating natural water sources is generally not feasible, so contaminated natural water sources must be contained to prevent public and animal use (see References: Hodges 2010).
The risk of environmental contamination following an intentional release of F tularensis is expected to be minimal, and no special environmental decontamination procedures are recommended (see References: Dennis 2001).

Issues Related to Autopsies and Burial

Autopsy practices

Recent guidelines from the CDC indicate that Standard Precautions should be used for postmortem care. These include using a surgical scrub suit, surgical cap, impervious gown or apron with full sleeve coverage, a form of eye protection (eg, goggles or face shield), shoe covers, and double surgical gloves with an interposed layer of cut-proof synthetic mesh (see References: CDC 2004).
In addition, autopsy personnel should wear N-95 respirators during all autopsies, regardless of suspected or known pathogens. Powered air-purifying respirators (PAPRs) equipped with N-95 or high-efficiency particulate air (HEPA) filters should be considered.
Procedures that induce aerosols or splashing should be avoided if possible.

Burial

Contact with corpses should be limited to trained personnel, and routine precautions should be implemented when transporting corpses.
Bodies infected with biological terrorism agents should not be embalmed (see References: CDC 2004). Bodies infected with F tularensis can be directly buried without embalming.

Public Health Reporting and Case Definitions

Tularemia was removed from the list of Nationally Notifiable Diseases in 1994 but was reinstated in 2000 because of concerns about tularemia as a biological weapon (see References: CDC 2002: Summary of Notifiable Diseases—United States, 2000). Cases of tularemia should be reported immediately to public health authorities, according to disease reporting rules within each state or local jurisdiction.

In 1997, the Council of State and Territorial Epidemiologists (CSTE) and the CDC revised the public health case definitions for conditions under public health surveillance (see References: CDC 1997). The current public health case definitions for tularemia include the following.

Clinical Description

An illness characterized by several distinct forms, including the following:

Glandular (regional lymphadenopathy with no ulcer)
Ulceroglandular (cutaneous ulcer with regional lymphadenopathy)
Pneumonic (primary pleuropulmonary disease)
Oculoglandular (conjunctivitis with preauricular lymphadenopathy)
Oropharyngeal (stomatitis or pharyngitis or tonsillitis and cervical lymphadenopathy)
Intestinal (intestinal pain, vomiting, and diarrhea)
Typhoidal (febrile illness without early localizing signs and symptoms)

Clinical diagnosis is supported by evidence or history of a tick or deerfly bite, exposure to tissues of a mammalian host of F tularensis, or exposure to potentially contaminated water.

Laboratory Criteria for Diagnosis

Presumptive:

Elevated serum antibody titer(s) to F tularensis antigen (without documented fourfold or greater change) in a patient with no history of tularemia vaccination or
Detection of F tularensis in a clinical specimen by fluorescent assay

Confirmatory:

Isolation of F tularensis in a clinical specimen or
Fourfold or greater change in serum antibody titer to F tularensis antigen

Case Classification

Probable: A clinically compatible case with laboratory results indicative of presumptive infection

Confirmed: A clinically compatible case with confirmatory laboratory results

Recognition of Unusual Events

Early disease outbreak recognition may significantly modify the outcome of a biological attack. A list has been developed of potential epidemiologic clues or "red flags" for an unusual event. Although these clues may be associated with natural outbreaks and bioterrorism events, their occurrence should heighten suspicion. Potential clues include the following (see References: Dembek 2007):

Highly unusual event with large numbers of casualties
Higher morbidity or mortality than is expected
Uncommon disease
Unusual disease manifestation
Lower attack rates in protected persons
Point-source outbreak
Multiple epidemics
Downwind plume pattern
Dead animals
Reverse or simultaneous spread of human and animal cases
Direct evidence

Several naturally occurring outbreaks have had characteristics of an unusual event; one of these was the 2000 Martha's Vineyard tularemia outbreak. Of the clues listed above, the first four were present in the Martha's Vineyard outbreak. After investigation, the proposed exposure scenario for this outbreak was that F tularensis was shed in animal excreta, persisted in the environment, and infected humans via mechanical aerosolization and inhalation.

In 2006, an animal control contractor observed a jackrabbit die-off near a metropolitan airport in Texas. Inspection of the area also revealed a large number of ticks. Specimens from several mammals (jackrabbits, a skunk, and a coyote) and ticks tested positive for F tularensis. Further investigation determined the die-off most likely was due to epizootic tularemia, and suspicion of a bioterrorism event was low. A coordinated, multiagency response was organized, however, because of proximity to human traffic areas and fears of transmission of tularemia to humans via contact with infected animals, vectors, or aerosolization of live bacteria. No human tularemia cases occurred, and the tularemia epizootic subsequently ended; the favorable outcome may have been due to the response efforts or spontaneous resolution. During an after-action analysis, the following were identified as lessons learned (see References: Pierce 2009):

The importance of animal illness surveillance
The usefulness of pre-event response planning, training, and exercises
The importance of familiarity with the CDC category A bioterrorism agents for rapid response
The usefulness of an established, effective communication system with the healthcare community
The possibility that environmental control attempts may result in perturbations in animal populations with unintended consequences

Images

Images of F tularensis Gram stain, direct fluorescent antibody stain, and colony morphology can be viewed on the CDC's Web site (see References: CDC: Public Health Image Library).

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