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Tularemia

Tularemia. Francisella tularensis. History. Discovered early 20 th century Tulare county, California “deerfly” fever. History. Discovered early 20 th century Tulare county, California “deerfly” fever Bioweapon potential Incapacitating . History. Discovered early 20 th century

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Tularemia

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  1. Tularemia Francisella tularensis

  2. History • Discovered early 20th century • Tulare county, California • “deerfly” fever

  3. History • Discovered early 20th century • Tulare county, California • “deerfly” fever • Bioweapon potential • Incapacitating

  4. History • Discovered early 20th century • Tulare county, California • “deerfly” fever • Bioweapon potential • Incapacitating • Former US and USSR production

  5. History • Discovered early 20th century • Tulare county, California • “deerfly” fever • Bioweapon potential • Incapacitating • Former US and USSR production • Prior use • Unit 731, Manchuria

  6. Epidemiology • Distribution • Moderate climates – U.S., Europe, Russia, Japan

  7. Epidemiology • Distribution • Moderate climates – U.S., Europe, Russia, Japan • 125 annual U.S. cases – mostly Midwest

  8. Epidemiology • Distribution • Moderate climates – U.S., Europe, Russia, Japan • 125 annual U.S. cases – mostly Midwest • Zoonosis • Small mammals (rabbits)

  9. Epidemiology • Transmission • Skin contact - e.g. infected animal

  10. Epidemiology • Transmission • Skin contact - e.g. infected animal • Arthropod bite – ticks

  11. Epidemiology • Transmission • Skin contact - e.g. infected animal • Arthropod bite – ticks • Aerosolization - BT attack; lawn mowers

  12. Epidemiology • Transmission • Skin contact - e.g. infected animal • Arthropod bite – ticks • Aerosolization - BT attack; lawn mowers • Mortality • <2% overall, 30-60% untreated pneumonic

  13. Epidemiology • Forms of disease

  14. Epidemiology • Forms of disease • Pneumonic (<5% of cases) • Expected in aerosol release

  15. Epidemiology • Forms of disease • Pneumonic (<5% of cases) • Expected in aerosol release • Ulceroglandular (45-85%)

  16. Epidemiology • Forms of disease • Pneumonic (<5% of cases) • Expected in aerosol release • Ulceroglandular (45-85%) • Glandular (5-25%)

  17. Epidemiology • Forms of disease • Pneumonic (<5% of cases) • Expected in aerosol release • Ulceroglandular (45-85%) • Glandular (5-25%) • Oculoglandular (<5%)

  18. Epidemiology • Forms of disease • Pneumonic (<5% of cases) • Expected in aerosol release • Ulceroglandular (45-85%) • Glandular (5-25%) • Oculoglandular (<5%) • Oropharyngeal (<5%)

  19. Epidemiology • Forms of disease • Pneumonic (<5% of cases) • Expected in aerosol release • Ulceroglandular (45-85%) • Glandular (5-25%) • Oculoglandular (<5%) • Oropharyngeal (<5%) • Typhoidal (<5-15%)

  20. Microbiology • Pleomorphic Gram negative coccobacillus • Usually not visible in clinical specimens • Small (0.2 m), aerobic • Non-motile, non-sporulating

  21. Microbiology • Pleomorphic Gram negative coccobacillus • Usually not visible in clinical specimens • Small (0.2 m), aerobic • Non-motile, non-sporulating • Fastidious • Slow growth (2-3+ days) • Requires cysteine-enriched media

  22. Microbiology • Pleomorphic Gram negative coccobacillus • Usually not visible in clinical specimens • Small (0.2 m), aerobic • Non-motile, non-sporulating • Fastidious • Slow growth (2-3+ days) • Requires cysteine-enriched media • 2 major strains (A and B) • A predominates in U.S., higher mortality

  23. Pathogenesis • Inoculation of virulent organisms

  24. Pathogenesis • Inoculation of virulent organisms • Local infection at site • Lung – bronchiolitis, pneumonitis, pleuritis

  25. Pathogenesis • Inoculation of virulent organisms • Local infection at site • Lung – bronchiolitis, pneumonitis, pleuritis • Migrate to regional lymph nodes

  26. Pathogenesis • Inoculation of virulent organisms • Local infection at site • Lung – bronchiolitis, pneumonitis, pleuritis • Migrate to regional lymph nodes • Hematogenously seed multiple organs

  27. Pathogenesis • Inoculation of virulent organisms • Local infection at site • Lung – bronchiolitis, pneumonitis, pleuritis • Migrate to regional lymph nodes • Hematogenously seed multiple organs • Suppurative immune response

  28. Clinical Features • All forms of disease • Acute onset • Initial flu-like illness • Fevers, chills, sweats, headache

  29. Clinical Features • All forms of disease • Acute onset • Initial flu-like illness • Fevers, chills, sweats, headache • Lower back myalgias

  30. Clinical Features • All forms of disease • Acute onset • Initial flu-like illness • Fevers, chills, sweats, headache • Lower back myalgias • Incubation 2-5 days (range 1-21)

  31. Clinical Features • All forms of disease • Pulmonary symptoms • Cough, dyspnea, chest pain (40%)

  32. Clinical Features • All forms of disease • Pulmonary symptoms • Cough, dyspnea, chest pain (40%) • Pulse/temperature dissociation (40%)

  33. Clinical Features • Pneumonic form

  34. Clinical Features • Pneumonic form • Symptoms • Nonproductive cough, +/- hemoptysis • Dyspnea, pleuritic pain

  35. Clinical Features • Pneumonic form • Symptoms • Nonproductive cough, +/- hemoptysis • Dyspnea, pleuritic pain • Chest radiograph • Infiltrates – patchy, bilateral • Effusions common

  36. Clinical Features • Ulceroglandular form

  37. Clinical Features • Ulceroglandular form • Ulcer – painful maculopapule, pustule, ulcer

  38. CDC/Emory University/Dr. Sellers. PHIL1344

  39. Diagnosis • High index of suspicion

  40. Diagnosis • High index of suspicion • No readily available rapid tests

  41. Diagnosis • High index of suspicion • No readily available rapid tests • Gram stain unhelpful

  42. Diagnosis • High index of suspicion • No readily available rapid tests • Gram stain unhelpful • Gold Standards • Serology (retrospective) • Culture (insensitive, hazardous, slow)

  43. Diagnosis • High index of suspicion • No readily available rapid tests • Gram stain unhelpful • Gold Standards • Serology (retrospective) • Culture (insensitive, hazardous, slow) • Rapid presumptive tests • DFA, IFA, PCR, IHC at reference labs

  44. Treatment • Supportive care • Parenteral antibiotics ASAP • Aminoglycosides • Streptomycin 1 g IM q12°

  45. Treatment • Supportive care • Parenteral antibiotics ASAP • Aminoglycosides • Streptomycin 1 g IM q12° • Gentamicin • Once-daily or traditional dosing

  46. Treatment • Supportive care • Parenteral antibiotics ASAP • Aminoglycosides • Streptomycin 1 g IM q12° • Gentamicin • Once-daily or traditional dosing • Tetracyclines – higher relapse rate • Doxycycline 100 mg IV q12° • Tetracycline - oral

  47. Treatment • Parenteral antibiotics • Others • Chloramphenicol – for meningitis

  48. Treatment • Parenteral antibiotics • Others • Chloramphenicol – for meningitis • Ciprofloxacin

  49. Treatment • Parenteral antibiotics • Others • Chloramphenicol – for meningitis • Ciprofloxacin • Ineffective agents • ß-lactams, macrolides

  50. Treatment • Duration of therapy • 10 (aminoglycosides) – 21 (tetracyclines) days • Switch to oral therapy when clinically improved

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