1/
25M
- 4d ago HA, myalgias➡️dx’d sinusitis, rx'd Amox
- 2d cough, high fever
- Today CXR: infiltrate on R, small pleural effusion.⬆️LFTs
Landscaper in Marthas Vineyard. No known tick bite. Fevers cont despite change to Ceftriaxone, should we...
#IDTwitter #IDMedEd #IDFellows
25M
- 4d ago HA, myalgias➡️dx’d sinusitis, rx'd Amox
- 2d cough, high fever
- Today CXR: infiltrate on R, small pleural effusion.⬆️LFTs
Landscaper in Marthas Vineyard. No known tick bite. Fevers cont despite change to Ceftriaxone, should we...
#IDTwitter #IDMedEd #IDFellows
2/
Dx: Pneumonic tularemia!
🔸May be a difficult dx. Unlike some forms of tularemia, there are not classic distinguishing features to separate it from CAP/atypicals.
🔸Might see lack of improvement on routine abxs, neg cxs
🔸Inhalation or hematogen spread from other forms (2ary)
Dx: Pneumonic tularemia!
🔸May be a difficult dx. Unlike some forms of tularemia, there are not classic distinguishing features to separate it from CAP/atypicals.
🔸Might see lack of improvement on routine abxs, neg cxs
🔸Inhalation or hematogen spread from other forms (2ary)
3/
Francisella spp, usu tularensis (others in humans: philomiragia, hispaniensis)
🦠GN coccobacillus
🧫Most require cysteine or cystine for growth, so usually doesn’t grow on most routine media
🚨Notify your lab if you suspect as needs special biosafety lab procedures
Francisella spp, usu tularensis (others in humans: philomiragia, hispaniensis)
🦠GN coccobacillus
🧫Most require cysteine or cystine for growth, so usually doesn’t grow on most routine media
🚨Notify your lab if you suspect as needs special biosafety lab procedures
4/
Routes of transmission:
🐇Direct or indirect animal contact (rabbits, squirrels, voles, muskrats, beavers, &more)
🔺Insect bites (that prev fed on infected animal) - vector depends on location
🌬️Airborne
🥤Ingestion contaminated meat/water
Routes of transmission:
🐇Direct or indirect animal contact (rabbits, squirrels, voles, muskrats, beavers, &more)
🔺Insect bites (that prev fed on infected animal) - vector depends on location
🌬️Airborne
🥤Ingestion contaminated meat/water
5/
🗺️Occurs throughout N.America, Europe. CDC map for 🇺🇸👇
⭐️Since we're in MA: The only 2 reported outbreaks of pneumonic tularemia in US occurred in Marthas Vineyard 1978+2000 (PMID11757506)
🌱Lawn mowing, brush cutting were risk factors, often landscapers
📰Links in last tweet
🗺️Occurs throughout N.America, Europe. CDC map for 🇺🇸👇
⭐️Since we're in MA: The only 2 reported outbreaks of pneumonic tularemia in US occurred in Marthas Vineyard 1978+2000 (PMID11757506)
🌱Lawn mowing, brush cutting were risk factors, often landscapers
📰Links in last tweet
6/
🔹Initial nonspecific sxs, abrupt onset. Incub period 3-5d
Major clinical forms often overlap:
✳️Pneumonic:
▪️Pl eff exudative, lymph predominant, may have ⬆️ADA, and bx would have granulomas ➡️ so can be confused with TB! pubmed.ncbi.nlm.nih.gov/8620743/
Other forms next tweet
🔹Initial nonspecific sxs, abrupt onset. Incub period 3-5d
Major clinical forms often overlap:
✳️Pneumonic:
▪️Pl eff exudative, lymph predominant, may have ⬆️ADA, and bx would have granulomas ➡️ so can be confused with TB! pubmed.ncbi.nlm.nih.gov/8620743/
Other forms next tweet
7/
✳️Ulceroglandular: most common. classic skin ulcer+ regional LAD - may become eschar
✳️Glandular: painful LAD
✳️Pharyngeal: sore throat, cervical LAD
✳️Typhoidal: systemic febrile illness, may p/w FUO
✳️Oculoglandular: Parinauds oculoglandular syndrome (conjunctivitis + LAD)
✳️Ulceroglandular: most common. classic skin ulcer+ regional LAD - may become eschar
✳️Glandular: painful LAD
✳️Pharyngeal: sore throat, cervical LAD
✳️Typhoidal: systemic febrile illness, may p/w FUO
✳️Oculoglandular: Parinauds oculoglandular syndrome (conjunctivitis + LAD)
8/
🧪Serologic dx most common:
▪️single titer >1:128 (microagglutination) or >1:160 (tube agglutination) with compatible sxs
▪️4 fold rise repeated after 10-14d is definitive serologic dx
🧫Cx rarely +, special media - but remember to let your lab know if suspect!
🧪Serologic dx most common:
▪️single titer >1:128 (microagglutination) or >1:160 (tube agglutination) with compatible sxs
▪️4 fold rise repeated after 10-14d is definitive serologic dx
🧫Cx rarely +, special media - but remember to let your lab know if suspect!
9/
💊Streptomycin (str), gent = drugs of choice mod-severe dz. 1st few days of str can induce Jarisch-Herxheimer like rxn
💊Mild: can use cipro, doxy
💊Aminoglycosides into CSF may be inadequate for meningitis. Use str or gent + doxy or chloramphenicol
💊Streptomycin (str), gent = drugs of choice mod-severe dz. 1st few days of str can induce Jarisch-Herxheimer like rxn
💊Mild: can use cipro, doxy
💊Aminoglycosides into CSF may be inadequate for meningitis. Use str or gent + doxy or chloramphenicol
10/
Beta-lactams assoc'd w/clin failure despite favorable in vitro susc, low MICs
pubmed.ncbi.nlm.nih.gov/8110955/
Beta-lactams assoc'd w/clin failure despite favorable in vitro susc, low MICs
pubmed.ncbi.nlm.nih.gov/8110955/
11/
MV outbreaks: nejm.org/doi/full/10.10…
nejm.org/doi/full/10.10…
pubmed.ncbi.nlm.nih.gov/17442781/
Another interesting paper on hx of tularemia: …nlm-nih-gov.ezp-prod1.hul.harvard.edu/30146078/
MV outbreaks: nejm.org/doi/full/10.10…
nejm.org/doi/full/10.10…
pubmed.ncbi.nlm.nih.gov/17442781/
Another interesting paper on hx of tularemia: …nlm-nih-gov.ezp-prod1.hul.harvard.edu/30146078/
