Emergency Preparedness

Kern Medical Bioterrorism Response Guide Section 2-A-5 – Tularemia ( Francisella tularensis )

? Granulomas may develop and occasionally caseate and may be confused with tuberculosis ? Secondary skin rashes can occur within the first two weeks of illness in up to 35% of cases Systemic tularemia ? Febrile illness without typical clinical features of other forms of tularemia, ? Non descript symptoms also include fever, chills, headache, myalgias, cough, sore throat, nausea, vomiting, watery diarrhea (rarely bloody), and abdominal pain, ? More common in persons with chronic diseases and may lead to rapiddeath or protracted illness. Oropharyngeal, Ulceroglandular, Glandular, and Oculoglandular Tularemia (unlikely bioaerosol release presentations) (contaminated food and water) causing a sore throat with e xudative tonsillitis and pharyngitis with the formation of ulcer(s); also may involve cervical, preparotid, and retropharyngeal lymph nodes with possible abscess formation. ? Ulceroglandular and glandular tularemia generally present withenlarged, local tender lymph nodes. Skin lesions can appear before, simultaneously, or after lymphadenopathy. The ulcers start as red, painful papule(s) that progress to necrotic draining ulcers with raised borders. ? Glandular tularemia is the same as ulceroglandular without the skin lesions. ? Oculoglandular tularemia results from the inoculation of bacteria onto the eye resulting in photophobia and excessive lacrimation, swollen eyes, painful infected conjunctiva and yellowish conjunctival ulcers. Laboratory Initial laboratory findings are generally nonspecific. Peripheral white blood cell count ranges from 5,000 – 22, 000 cells per microliter with a normal differential count. Lymphocytosis may occur late in the disease. Hematocrit, hemoglobin, and platelet counts are generally normal. Mild elevations in lactic dehydrogenase, serum transaminases and alkaline phosphatase are common. Rhabdomyolysis may be associated with elevations in serum creatine kinase and urinary myoglobin levels. Cerebral spinal fluid is generally normal although mild abnormalities in protein, glucose and blood cell count may be seen. Tularemia can be diagnosed by recovery of the organism from blood, ulcers, conjunctival exudates, sputum, gastric washings, and pharyngeal exudates. The organism grows poorly on standard culture media and requires cysteine -enriched media. Most diagnoses of tularemia are made serologically. ? Oropharyngeal tularemia results from the direct invasion of the oropharynx

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