Tularemia

 

Welcome to PT 635 Pathophysiology of Complex Patient Problems This is a wiki created by and for the students in the School of Physical Therapy at Bellarmine University in Louisville KY. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Definition/Description

Tularemia, named after the infectious gram-negative bacterium Francisella tularensis, is a zoonotic disease. A zoonotic disease is one that is spread from animal to human (infected humans can NOT pass the disease to other humans). This spread may be directly i.e. handling contaminated meat or through a carrier i.e. a tick. It is also known as “Ohara’s disease”, “rabbit fever”, “deer-fly fever”,[1] “market’s men disease”, “meat-cutter’s disease”, “glandular type of tick fever”, “water rat-trappers’ disease”. It is highly infectious, <10 organisms causing severe disease in both humans and animals.[2] There are 4 sub-types of the bacterium, the most common in the United States are Type A, tularenis, and Type B, holarctica. It is on the Center for Disease Control’s list of bioterroism threats.


 
http://sfcdcp.org/tularemia.html

Prevalence

The prevalence of Tularemia in the United States depends on the geographical location and the time of year. During the spring and summer months (May-September), there is a rise in reported cases. South-Central, Pacific Northwest, and parts of the East Coast have the highest incidence of Tularemia. While the population most effected is young males 5-9 years old and those > 75 years old.[3]

Image:Tularemia_Image_1.jpg

Image:Tularemia_Image_2.jpg

Image:Tularemia_Image_3.jpg

The above images from: http://www.cdc.gov/tularemia/statistics/.

Characteristics/Clinical Presentation[4][5][6][3][1]

  • Fever
  • Abdominal pain
  • Arthralgias
  • Shortness of breath
  • Malaise
  • Nausea/Vomiting
  • Sore throat
  • Tender local lymph nodes                                         
  • Chills
  • Prostration
  • Conjunctivitis
  • Diaphoresis
  • Axillary adenopathy
  • Non-Productive Cough
  • Hemoptysis
  • Pt usually presents w/ what appears to be community acquire pneumonia, however it does not respond to conventional treatment
  • Headache
  • Myalgias
  • Cutaneous ulcers
  • Weight loss
  • Epitrochlear adenopathy
  • Pleuritic chest pain, retrosternal pain
  • Painful skin lesion @ site of infection (ulceroglandular only)                                 

Note: The 2 most common forms are glandular/ulcerglandular and pneumonic.
Those occurring in ≥25% of those infected with the glandular and ulceroglandular form are in bold[4]
Those occurring in ≥25% of those infected with the pneumonic form are in italics[4]  


        

http://pathmicro.med.sc.edu/ghaffar/zoonoses.htm
                   
http://www.cdc.gov/ncidod/eid/vol8no1/01-0131G1.htm
                                        

 


Expectations/Prognosis[5]

Untreated: Fatality ~5%

Treated: Fatality <1%


Poor outcomes have been associated with those who have underlying co-morbidities such as alcoholism or diabetes and those who delay seeking medical treatment.[4]

Medications[4]

Antibiotic therapy is used to treat Tularemia. Streptomyocin and Gentamicin are usually the first administered. Ciprofloxacin along with other fluoroquinolones. Tetracycline and chloramphenicol may also be used to treat Tularemia, however they have higher relapse rates than the previously mentioned.

Resistant to beta-lactam antibiotics and azithromycin.

Diagnostic Tests/Lab Tests/Lab Values[4][5]

There are numerous ways to test for F. tularensis:
• Gold Standard: Bacteriologic Culture[2]
• Most Common: Serology[2]
• Polymerase Chain Reaction of sample ulcer
• Direct Stains
• Blood Culture
• Direct Fluorescent Antibody Stain
• Slide Agglutination
• Antimicrobial Susceptibility
• Biochemical Identification
• Enviornmental Specimen Evaluation
• Chest X-ray

Beaver

Etiology/Causes [2]

Direct transmission occurs from direct contact with the infected animal or direct contact from soil, water, or landscape. This may be from ingestion of contaminated meat (most likely rabbit), water, or inhaled dust. It can also be passed from handling or skinning contaminated animals or from a bite/scrath from a contaminated animal. Animal hosts that may spread Tularemia include lagomorphs (rabbit and hare), rodents, insectivores, carnivores, ungulates, marsupials, birds, amphibians, fish, and invertebrates. Secondary carriers include ticks, mosquitoes, biting flies or deerfly. With such a wide variety of hosts and carriers available of this disease, it is has the possibility to appear/outbreak in other regions.

http://www.wormsandgermsblog.com/tags/tularemia/
http://www.mybwmc.org/library/2/19660

Systemic Involvement [4],[5]

  • Supporation of local lymph nodes
  • 2o Pneumonia
  • Hematogenous Spread to other organs resulting in:

     Pericarditis

     Osteomyelitis

     Meningitis

     Sepsis

     Hepatitis/Jaundice

     Splenic Rupture

     Encephalitis

     Peritonitis

  • Renal Failure
  • Rhabomyolisis (typhoidal form)
  • ARDS (penumonic form)
  • Lung Abscess (pneumonic form)
  • Fibrosis/Calcification of affected lung areas (pneumonic form)
  • Pleuritis (pneumonic form)


With all forms of Tularmemia illness MAY result in such debilitating conditions (more so when other systems are     involved), that recovery can take several months.

   

Medical Management (current best evidence) 

Antimicrobials are currently the best treatment option for Tularemia infections. After beginning treatment one should expect to see an improvement in symptoms and fever within 24-48 hours.[4]

       Tetracycline should not be used as a treatment in those whose permanent teeth have not came in.[5]

  • Quinolones
  • Contraindicated in those < 18 years of age
  • "well tolerated, achieve adequate blood levels...and have excellent intracellular penetration"[6]


A review of 10 documented treatment cases in the United States found that those treated with Aminoglycosides have a 6-12% relapse rate of infection, while those treated with Quinolones had a 0% relapse rate.[6]

Physical Therapy Management (current best evidence)

Currently did not come across any management in regards to physical therapy.

Points to consider:

  • Pt's with tularemia present with generalized musculoskeletal aches.
  • Pt's who have complications develop 2o to their primary Tularemia infection may take months to recover. During this time physical therapy may play a roll in conditioning,balance retraining, rebuilding strength and endurance, and regaining patient's independence in their functional roles in society and home.

Differential Diagnosis

Alternative Diagnosis

Differential Characteristics to rule out Tularemia


Glandular[4]

  • Bubonic Plague
    http://www.nzma.org.nz/journal/120-1248/2403/

        Systemic toxicity

  • Cat-Scratch Disease

         History of cat scratch

         Takes weeks to develop

  • Myobacterial Infection

Lymph Nodes painless/non-tender

  • Sporotrichosis

No systemic symptom

Lymph nodes painless

History of contact w/ soil/plants

Lesions along lymphatic chains 

  • Streptococcal
  • Lymphogranuloma Venereum

Adenitis in genital lymph chains only

  • Primary Genital Herpes

Adenitis in genital lymph chains only

  • Secondary Syphilis

Enlarged lymph nodes in inguinal region only

Ulceroglandular[4]

  • Anthrax

    Painless ulcer --> black eschar; non-pitting edema around lesion

  • Orf
    Pustule that progresses to weeping nodule
http://www.upmc-biosecurity.org/website/focus/agents_diseases/fact_sheets/tularemia.html
  • Pasteurella infections

    History of dog/cat bite or licking of open wound

  • Primary Syphillis

    Painless ulcer at genital site

  • Ricketsialpox

    Painless papule --> black eschar; maculopapular rash in 2-3 days

  • Scrub Typhus

    Maculopapular rash; Infection from chigger bites

  • Staphylococcal/Stretococcal Cellulitis

    History of trauma or pre-existing lesion

Pneumonic [4]

  • Community Acquired Pneumonia
    http://cchealth.org/topics/bioterrorism/providers/how_to_recognize.php

Won't cure with conventional antibiotic therapy

  • Inhalation of Anthrax

Often fulminant

  • Pneumonic Plague

Consolidation on Chest X-ray

Often Fulminant

  • Q Fever

Exposure to sheep, goat, cattle, cat

Difficult to differentiate from Tularemia

  • Tuberculosis

More common in elderly and those living in close living quarters

(shelters,jails,schools etc...)

  • Viral Pneumonia

Recent cruise or trip to tropics

Exposure to feces/urine of mice

  • Respiratory Syncytial Virus

More common in children during Winter and Spring

  • Cytomegalovirus

Oculoglandular [4]

  • Adenoviral Infection
  • Cat-Scratch Disease
  • Coccidiodomycosis
  • Herpes Infection
  • Pyogenic Bacterial Infections
  • Sporotrichosis
  • Syphilis
  • Tuberculosis

Oropharyngeal [4]

  • Streptococcal Pharyngitis
  • Infections Mononucleosis
  • Adenoviral Infection
  • Diptheria

Typhoidal [4]

  • Brucellosis
  • Disseminated Mycobacterial/Fungal Infection
  • Endocarditis
  • Leptspirosis
  • Pontiac Fever
  • Malaris
  • Q Fever
  • Typhoid Fever

Case Reports/ Case Studies


Isolation of Francisella tularensis from blood.[7]

Tularemia: Emergency department presentation of an infrequently recognized disease.[8]

Treatment of tularemia with fluoroquinolones: two cases and review.[9]

Resources

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001859/

http://emergency.cdc.gov/agent/tularemia/faq.asp

http://www.cdc.gov/tularemia/index.html

Recent Related Research (from Pubmed)

see tutorial on Adding PubMed Feed

Failed to load RSS feed from http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=10KSIBP312BDu6Ze6vpi05GEZXh4IK2Q9I44Hvc1UXvWiIeEp5: Error parsing XML for RSS

References

see adding references tutorial.

  1. 1.0 1.1 1.2 Wilson M, Lountzis N, Ferringer T. Zoonoses of dermatologic interest. Dermatologic Therapy. 2009;22:367-378. http://onlinelibrary.wiley.com/doi/10.1111/j.1529-8019.2009.01248.x/abstract. Accessed February 2011.
  2. 2.0 2.1 2.2 2.3 Petersen JM, Schriefer ME. Tularemia: emergence/re-emergence. Vet Res. 2005;36:455-467. http://digitalcommons.unl.edu/cgi/viewcontent.cgi?article=1031&context=zoonoticspub&sei-redir=1#search=%22Petersen+JM,+Schriefer+ME.+Tularemia:+emergence/re-emergence.%22. Accessed February 2011.
  3. 3.0 3.1 Hayes E, Marshall S, Dennis D. Tualremia--United States,1990-2000. www.cdc.gov/mmwr/preview/mmwrhtml/mm5109a1.htm. February 20, 2011.
  4. 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 CIDRAP. Tularemia: Current, comprehensive information on pathogenesis, microbiology, epidemiology, diagnosis, treatment, and prophylaxis. http://www.cidrap.umn.edu/cidrap/content/bt/tularemia/biofacts/tularemiafactsheet.html. Updated March 16, 2010. Accessed February 2011.
  5. 5.0 5.1 5.2 5.3 5.4 Tularemia. PubMed Health. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001859/. Updated March 17,2009. Accessed February 19, 2011.
  6. 6.0 6.1 6.2 Limaye AP, Hooper CJ. Treatment of tularemia with flouroquinolones: two cases and review. Clinical Infectious Diseases. 1999;29:922-924. http://www.ncbi.nlm.nih.gov/pubmed/10589911. Accessed February 2011.
  7. Provenza JM, Klotz SA, Penn RL. Isolation of francisella tularenis from blood. Journal of Clinical Microbiology. 1986;24:453-455. http://jcm.asm.org/cgi/content/short/24/3/453. Accessed February 2011.
  8. Harrell RE, Whitaker GR. Tularemia: Emergency department presentation of an infrequently recognized disease. Am J Emerg Med. 1985;3:415-418. http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6W9K-4C4FJTF-GS&_user=10&_coverDate=09%2F30%2F1985&_rdoc=1&_fmt=high&_orig=gateway&_origin=gateway&_sort=d&_docanchor=&view=c&_rerunOrigin=google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=8437c09158b0597f13c1896c220c972e&searchtype=a. Accessed February 2011.
  9. Limaye AP, Hooper CJ. Treatement of tularemia with fluoroquinolones: Two cases and review. Clinical Infectious Diseases. 1999;29:922-924.http://www.ncbi.nlm.nih.gov/pubmed/10589911. Accessed February 2011.