History and exam

Key diagnostic factors

common

presence of risk factors

Key risk factors include tick or fly bites, contact with skin of infected animals (e.g., in hunters who skin rabbits), or outdoor work in areas where infected animals live.

fever

All forms of tularaemia are accompanied by systemic symptoms such as fever/chills.[1]​​ Fever, with a pulse-temperature deficit, is seen in one half of cases, remitting only after several days and with a high chance of a relapse.[1]​​

lymphadenopathy

Ulceroglandular and glandular tularaemia present with unilateral and localised tender lymphadenopathy. Pharyngeal and oculoglandular tularaemia may also be accompanied by regional lymphadenopathy.[1]​​ [Figure caption and citation for the preceding image starts]: Ulceroglandular tularaemia of the lower extremity from a tick bite; ulcer over the patella and ascending lymphadenopathy are evidentCourtesy of Barry Farr, MD, MPH [Citation ends].com.bmj.content.model.Caption@23783470

painful skin ulcer

In the ulceroglandular form, a painful ulcer where the organism was inoculated (by a tick or fly bite, or by direct contact with an infected animal) is found distal to the draining lymph nodes that are enlarged, and starts as a painful papule before ulcerating.[2]​​[3]​​[4]​​[5]​​[6]​​

unilateral conjunctivitis

Seen with oculoglandular tularaemia.[1]​​

Other diagnostic factors

common

headache

All forms of tularaemia are accompanied by systemic symptoms such as headache. Acute headache may rarely be a symptom of tularaemic meningitis or brain abscess.[1]​​

malaise/fatigue

All forms of tularaemia are accompanied by systemic symptoms such as malaise and fatigue.[1]​​

myalgia

All forms of tularaemia are accompanied by systemic symptoms such as myalgia.[1]​​

anorexia

All forms of tularaemia are accompanied by systemic symptoms such as anorexia.​[1]

abdominal pain

All forms of tularaemia are accompanied by systemic symptoms such as abdominal pain.[1]​​

vomiting

All forms of tularaemia are accompanied by systemic symptoms such as vomiting.[1]​​

rales

Heard on auscultation with pneumonic tularaemia.

non-productive cough/dyspnoea

Seen with pneumonic tularaemia. Dyspnoea occurs on exertion. Patients may also report chest tightness or pleuritic pain.[1]​​

sore throat

Seen with pharyngeal tularaemia. Associated with exudative pharyngitis or tonsillitis.[1]​​

photophobia

Occurs in oculoglandular tularaemia.​[1]

uncommon

vision impairment/loss

Occurs in oculoglandular tularaemia.[1]​​

jaundice, hepatosplenomegaly, diarrhoea

Seen in typhoidal tularaemia.

Jaundice is often accompanied by cholestasis.

positive Kernig's/Brudzinski's sign, stiff neck

Rare presentation seen in tularaemic meningitis.

Risk factors

strong

tick exposure

The dog tick Dermacentor variabilis, wood tick D andersoni, and Lone Star tick Amblyomma americanum are vectors for the spread of tularaemia.​[16]​​[17]​​

biting fly exposure

Can be acquired from biting deer flies in, for example, California, Nevada, and Utah in the West of the US.[17]​​

contact with infected animals

Contact with skin of infected animals (e.g., in hunters who skin rabbits)[2]​​[3]​​[17]​​

outdoor work in areas where infected animals live

Inhalational tularaemic pneumonia has been reported in people who do outdoor work in areas inhabited by infected animals.[7]​​[17]​​

spring or summer season

More common in spring and summer, as it can be a tick-borne disease, and this is when tick exposure is at its peak.[1]​​

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