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The most frequent complications are bone and joint lesions such as spondylitis and suppurative arthritis (usually of a single joint), endocarditis, and meningoencephalitis Less common complications are pneumonitis with pleural effusion, hepatitis, and cholecystitis
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A Symptoms and Signs
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Fever, headache, and nausea begin suddenly, and a local lesion a papule at the site of inoculation develops and soon ulcerates Regional lymph nodes may become enlarged and tender and may suppurate The local lesion may be on
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the skin of an extremity or in the eye Pneumonia may develop from hematogenous spread of the organism or may be primary after inhalation of infected aerosols, which are responsible for human-to-human transmission Following ingestion of infected meat or water, an enteric form may be manifested by gastrointestinal symptoms, stupor, and delirium In any type of involvement, the spleen may be enlarged and tender and there may be nonspecific rashes, myalgias, and prostration
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Plague is an infection of wild rodents with Yersinia pestis, a small bipolar-staining gram-negative rod It is endemic in California, Arizona, Nevada, and New Mexico It is transmitted among rodents and to humans by the bites of fleas or from contact with infected animals Following a fleabite, the organisms spread through the lymphatics to the lymph nodes, which become greatly enlarged (bubo) They may then reach the bloodstream to involve all organs When pneumonia or meningitis develops, the outcome is often fatal The patient with pneumonia can transmit the infection to other individuals by droplets The incubation period is 2 10 days Because of its extreme virulence, its potential for dissemination and person-to-person transmission, and efforts to develop the organism as an agent of biowarfare, plague bacillus is considered a high-priority agent for bioterrorism
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Culturing the organism from blood or infected tissue requires special media For this reason and because cultures of F tularensis may be hazardous to laboratory personnel, the diagnosis is usually made serologically A positive agglutination test (> 1:80) develops in the second week after infection and may persist for several years
Differential Diagnosis
Tularemia must be differentiated from rickettsial and meningococcal infections, cat-scratch disease, infectious mononucleosis, and various bacterial and fungal diseases
Clinical Findings
A Symptoms and Signs
The onset is sudden, with high fever, malaise, tachycardia, intense headache, delirium, and severe myalgias The patient appears profoundly ill If pneumonia develops, tachypnea, productive cough, blood-tinged sputum, and cyanosis also occur There may be signs of meningitis A pustule or ulcer at the site of inoculation and lymphangitis may be observed Axillary, inguinal, or cervical lymph nodes become enlarged and tender and may suppurate and drain With hematogenous spread, the patient may rapidly become toxic and comatose, with purpuric spots (black plague) appearing on the skin Primary plague pneumonia is a fulminant pneumonitis with bloody, frothy sputum and sepsis It is usually fatal unless treatment is started within a few hours after onset
Complications
Hematogenous spread may produce meningitis, perisplenitis, pericarditis, pneumonia, and osteomyelitis
Treatment
Streptomycin is drug of choice for treatment of tularemia The recommended dose is 75 mg/kg intramuscularly every 12 hours for 7 14 days Gentamicin, which has good in vitro activity against F tularensis, is generally less toxic than streptomycin and probably just as effective Doxycycline (200 mg/d orally) is also effective but has a higher relapse rate A variety of other agents (eg, fluoroquinolones) are active in vitro but their clinical effectiveness is less well established
Hassoun A et al Tularemia and once-daily gentamicin Antimicrob Agents Chemother 2006 Feb;50(2):824 [PMID: 16436758] Staples JE et al Epidemiologic and molecular analysis of human tularemia, United States, 1964 2004 Emerg Infect Dis 2006 Jul;12(7):1113 8 [PMID: 16836829]
B Laboratory Findings
The plague bacillus may be found in smears from aspirates of buboes examined with Gram stain Cultures from bubo aspirate or pus and blood are positive but may grow slowly In convalescing patients, an antibody titer rise may be demonstrated by agglutination tests
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