Snapshot A 34-year-old man presents to the emergency room for acute-onset fever, pain in the eyes, and ulcer. He has not been to the physician in years, so his past medical history is unknown. He currently works at an angora rabbit farm and interacts with the animals daily. He reports being bit recently on his forearm, where there is now a lesion. On physical exam, he is febrile. He has severe conjunctival injection bilaterally and has multiple 1-2-cm tender cervical lymph nodes. On his left forearm, there is a 1-cm ulcer with elevated edges. Introduction Classification Francisella tularensis an aerobic gram - coccobacilli transmission hosts include ticks, rabbits, and deer flies bites from exposed animals inhalation of organism Epidemiology incidence rare demographics south-central United States risk factors exposure to small mammals (rabbits, voles, muskrats, etc.) Pathogenesis inoculation of the skin or mucous membranes leads to spread of organism to the lymph nodes and other organs inhalation may result in pulmonary disease Associated conditions ulceroglandular tularemia (most common) typhoidal tularemia pulmonary tularemia may accompany both ulceroglandular (< 50% of cases) or typhoidal (80% of cases) tularemia Prognosis symptoms arise acutely < 1 week after exposure patients with pneumonia have the highest mortality Presentation Symptoms ulceroglandular headache painful conjunctivitis pharyngitis typhoidal nausea vomiting Physical exam high fever ulceroglandular tender maculopapular rash initially lesion may ulcerate with a raised border tender lymphadenopathy typhoidal hepatomegaly splenomegaly pneumonia Imaging Chest radiography indication suspected pulmonary involvement findings pulmonary infiltrates hilar lymphadenopathy pleural effusion Studies Labs culture is hazardous positive titers on serology diagnostic Making the diagnosis based on clinical presentation, risk factors, and serology Differential Cat-scratch disease distinguishing factor lymphadenopathy with papular, pustular, or vesicular lesions without ulceration at the site of inoculation Brucellosis distinguishing factor often presents with osteoarticular disease, such as osteomyelitis or arthritis Treatment Medical aminoglycosides indication first-line for all patients drugs gentamicin streptomycin ciprofloxacin indication patients who cannot tolerate aminoglycosides Complications Renal failure Meningitis Erythema nodosum