Glandular Tularemia

https://www.nejm.org/doi/full/10.1056/NEJMicm1801531

Glandular Tularemia

  • Laura Marks, M.D., Ph.D.,
  • and Andrej Spec, M.D.
nejmicm1801531_f1

A 68-year-old man from Missouri presented to the primary care clinic with a history of 1 week of fever followed by 2 months of progressive, painful swelling on the right side of his neck. Approximately 2 days before the onset of the patient’s symptoms, his outdoor cat died from a subacute illness; a veterinarian had diagnosed feline leukemia without laboratory testing, and the cat had been treated with prednisone, which the patient administered. The patient’s physical examination revealed three erythematous, tender lymph nodes. The remainder of the physical examination was normal. Serologic testing with IgM antibody was positive for Francisella tularensis (titer, 1:1280). A diagnosis of glandular tularemia was made. Glandular tularemia is the second most common manifestation of tularemia after the ulceroglandular form. Because culture requires biosafety level 3 conditions, diagnosis is often confirmed serologically. Domestic cats can become infected through the consumption of infected prey and can transmit the bacteria to humans. The patient was treated with doxycycline for 4 weeks; the lesions improved within 5 days and resolved within 3 weeks.


Laura Marks, M.D., Ph.D.
Barnes–Jewish Hospital, St. Louis, MO

Andrej Spec, M.D.
Washington University in St. Louis, St. Louis, MO

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**Comment**

I remember hearing Timothy Lepore, MD, FACS, surgeon at Nantucket Cottage Hospital, at a Lyme conference.  He explained that Tularemia is also a disease of those who work with the land such as landscapers and farmers, as well as those who get bit by a tick. There are cases reported in every state but Hawaii, and many other wild and domestic animals can be infected. The highest rates of infection are in Arkansas.  Please see this link for more details but know that this is a bioweaponized pathogen:  https://madisonarealymesupportgroup.com/2016/10/25/of-rabbits-and-men/  The WHO estimates that an aerosol dispersal of 50 kg of F. tularensis over an area with 5 million people would result in 25,000 incapacitating casualties including 19,000 deaths.

For hunters:  https://madisonarealymesupportgroup.com/2018/08/07/tularemia-hunting-dogs-as-possible-vectors/  “The frequency of about seven percent shows that hunting dogs can also become infected regularly. As vectors of the disease, even without symptoms, the animals must also be considered unexpected carriers,” Posautz adds.