Case history

Case history #1

A 60-year-old man is admitted to hospital with a 10-day history of exertional dyspnoea, chills, myalgia, headache, fever, and night sweats. He works on a farm and has daily exposure to rabbits, horses, sheep, turkeys, and chickens. On examination his temperature is 38.5°C (101.3°F), pulse 75 bpm, respiratory rate 22 breaths per minute, and blood pressure 100/80 mmHg. Chest x-ray demonstrates an area of consolidation in the left-upper and right-upper lobes and a small pleural effusion on the left.

Case history #2

A 16-year-old boy with a history of seizures was seen with a 1-day history of fever, rhinorrhoea, and fatigue. He was treated with amoxicillin/clavulanate for presumed sinusitis but admitted later that day after a tonic-clonic seizure. A paronychia was noted on the right middle finger; this was drained and he was discharged on dicloxacillin. Three days later he is readmitted with fever, right-middle-finger pain, and axillary pain. On examination his temperature is 38.5°C (101.5°F), pulse 116 bpm, respiratory rate 24 breaths per minute, and blood pressure 122/76 mmHg. A large, tender, palpable node in the right axilla is found. The patient had recently been rabbit hunting and also had a recent cat scratch and mosquito bites, but there was no known tick exposure.[3]​​

Other presentations

Systemic manifestations are usually abrupt in onset. Signs and symptoms depend on the organ affected, which in itself is dependent on the site of entry of the bacteria. Although ulceroglandular tularaemia (unilateral and localised tender lymphadenopathy with ulcer at site of inoculation) is the most common presentation, other, less common presentations include glandular (the same as ulceroglandular presentation but without a visible skin lesion), pneumonic (non-productive cough, dyspnoea, chest tightness, rales, pleurisy, exudative pleural effusions), pharyngeal (sore throat, exudative pharyngitis or tonsillitis), oculoglandular (unilateral conjunctivitis in most cases, often accompanied by photophobia, vision impairment/loss, sub-mandibular, cervical, or pre-auricular lymphadenopathy), typhoidal (diarrhoea, jaundice, cholestasis, hepatosplenomegaly), or rarely meningitis and brain abscess (stiff neck, acute headache, Kernig's and Brudzinski's signs).[2]​​[3]​​[4]​​[5][6][7][8][9][10][12] ​​​​ The bacterium contains endotoxin, and endotoxic shock can be one presentation of the infection.[1]​ Asymptomatic infection may occur, but there are no data on the incidence of this.

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