History and exam

Key diagnostic factors

common

fever

All forms of tularemia 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 tularemia present with unilateral and localized tender lymphadenopathy. Pharyngeal and oculoglandular tularemia may also be accompanied by regional lymphadenopathy.[1]​​ [Figure caption and citation for the preceding image starts]: Ulceroglandular tularemia 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@74570908

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 tularemia.[1]​​

Other diagnostic factors

common

headache

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

malaise/fatigue

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

myalgia

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

anorexia

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

abdominal pain

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

vomiting

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

rales

Heard on auscultation with pneumonic tularemia.

nonproductive cough/dyspnea

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

sore throat

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

photophobia

Occurs in oculoglandular tularemia.[1]​​

uncommon

vision impairment/loss

Occurs in oculoglandular tularemia.[1]​​

jaundice, hepatosplenomegaly, diarrhea

Seen in typhoidal tularemia.

Jaundice is often accompanied by cholestasis.

positive Kernig/Brudzinski sign, stiff neck

Rare presentation seen in tularemic 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 tularemia.​[15]​​[16]​​

biting fly exposure

Can be acquired from biting deer flies in, for example, California, Nevada, and Utah in the West of the US.[16]​​

contact with infected animals

Contact with skin of infected animals (e.g., in hunters who skin rabbits).[2]​​[3]​​[16]​​

yard work in areas where infected animals live

Inhalational tularemic pneumonia has been reported in people who do yard work in areas inhabited by infected animals.[7]​​[16]​​

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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