### Microbiology A little gram-negative rod (aka coccobacillus) that can have bipolar staining. *Francisella* *tularensis*, has 4 subspecies, but nearly all cases are due to subspecies *tularensis* (type A), the most virulent type found in North America, and subspecies *holarctica* (type B), which is the most widespread species in Europe. *Francisella* *tularensis* *F*. *novicida*, *F*. *philomiragia* and others. It can be difficult to grow, and the serology can cross-react with *Brucella*. *Francisella* will often take more than the standard 5 days the lab usually incubates blood cultures to grow. ### Epidemiologic Risks *Francisella* are over the Northern Hemisphere and Europe. Get the organism from skinning and eating rodents and lagomorphs (bunny rabbits) or being in contact with their excrement. Ticks (a common vector in the Southern US around Missouri), biting flies and mosquitoes can also spread disease, as can drinking water. There was a waterborne outbreak in Turkey. In Sweden, *Francisella* *tularensis* *holarctica* is spread by mosquitoes [^1] and hares and has been a major problem in Norway, [^2] in what they call the rodent years. I remember that TV show. And in Australia, it is ring-tailed possums that are the source. And, if you happen to be within 5 meters of hares that you are hosing down after skinning and disemboweling them, you can get pneumonic tularemia. [^3] So be careful splitting hares. There was a fatal case of pneumonic tularemia where the patient acquired the infection from her rabbit killing dog. Yet another reason you should not let your dog lick you. [^4] People get plague from their dogs and cats the same way. There are about 10 cases a year in the US, [^5] here have been increased cases in Colorado, Nebraska, South Dakota, and Wyoming in 2015. [^6] The best outbreak was pneumonic tularemia from rabbits being aerosolized by a lawnmower [^7]; I had a similar case. Now sing along with me. "Over in the gorge/Many many months ago,/ Me Mither killed a rabbit /In the mower it did go./ It aerosolized the bunny /In the good ould Toro way,/ Sending bacteria into the air/ To be sucked into the lung to stay. /Chorus: "Too-ra-loo-ra-le-mia, /Too-ra-loo-ra-li, /Too-ra-loo-ra-le-mia,/ now you are going to die /Too-ra-loo-ra-le-mia,/ Too-ra-loo-ra-li, /Too-ra-loo-ra-le-mia, /that's an ID lullaby." > "We report on an unusual case of oculoglandular tularemia acquired after crushing a tick removed from a dog. As a droplet sprayed into the patient's eye the eyelids became inflamed, and on the fourth day, a high fever started." [^8] In the Midwest, cats are the vector. [^9] In France, > "Patients became infected mainly through contact with rodents or game (38 cases, 21.4%), through tick-bites (23 cases, 12.9%), or during outdoor leisure activities (37 cases, 20.9%)...Tularemia was discovered incidentally in 54.8% of cases. [^10] And a case in an immunocompetent white, non-Hispanic woman aged 67 years from Sherburne County, Minnesota from a fishhook injury from *Francisella* *holarctica* (type B). [^11] *Francisella* has been spread by organ transplants; one donor had dead rabbits outside his house. [^12] [^13] And *Francisella* might be spread by the wind, at least in Arizona. [^14] *Francisella* can be found in fleas parasitizing common voles (*Microtus* *arvalis*) from northwestern Spain. [^15] ### Syndromes a) typhoidal: A febrile, low pulse illness, nonfocal, lasting for a month. A cause of Faget's. b) ulceroglandular: look for a necrotic ulcer at the site of inoculation. Can mimic herpes with a blister. [^16] c) glandular: many inflamed lymph nodes. d) oculoglandular (after skinning a rabbit, try not to stick your finger in your eye). e) pharyngeal. f) pneumonic.  A problem in Sweden. [^17] ### Treatment Streptomycin is the classic therapy, gentamicin is an acceptable substitute. Third-generation cephalosporins, carbapenems, other aminoglycosides, and quinolones work in the test tube, but little clinical experience. In Missouri, where they had a bunch of mostly misdiagnosed cases, accidental ciprofloxacin worked well. [^18] Do not use tetracycline. But, in one retrospective series, 21 days of a tetracycline with I&D worked. [^19] > "169 isolates (92 type A and 77 type B) from North America were tested against seven antimicrobial agents (streptomycin, gentamicin, tetracycline, doxycycline, ciprofloxacin, levofloxacin, and chloramphenicol) used for the treatment of tularemia. The MICs for all of the isolates fell within the susceptible range." [^20] ### Notes The organisms can survive for long periods of time in the environment. There are people fool enough to eat ill animals, as they are easy to catch. Mmmmmmmm, good. It is a biohazard so warn the lab as they need special media to grow. The best way to make the diagnosis is serology. Warn the lab if you are worried; they can catch the infection in the lab. ### Puswhisperers [An ID lullaby](http://www.pusware.com/PW2/AnIDLullaby.html) [Audio. The Gobbet 'o Pus Podcast](http://www.pusware.com/gobbet/gop327.mp3) [Ursine Questions](http://www.pusware.com/PW4/UrsineQuestions.html) [Audio. The Gobbet 'o Pus Podcast](http://www.pusware.com/gobbet/gop569.mp3) ### Rationalizations [^1]: Rydén P, Björk R, Schäfer ML, Lundström JO, Petersén B, Lindblom A, Forsman M, Sjöstedt A, Johansson A. Outbreaks of tularemia in a boreal forest region depends on mosquito prevalence. J Infect Dis. 2012 Jan 15;205(2):297-304. doi: 10.1093/infdis/jir732. Epub 2011 Nov 28. PMID: 22124130; PMCID: PMC3244368. [^2]: Larssen KW, Bergh K, Heier BT, Vold L, Afset JE. All-time high tularaemia incidence in Norway in 2011: report from the national surveillance. Eur J Clin Microbiol Infect Dis. 2014 Nov;33(11):1919-26. doi: 10.1007/s10096-014-2163-2. Epub 2014 May 31. PMID: 24874046. [^3]: Hauri AM, Hofstetter I, Seibold E, Kaysser P, Eckert J, Neubauer H, Splettstoesser WD. Investigating an airborne tularemia outbreak, Germany. Emerg Infect Dis. 2010 Feb;16(2):238-43. doi: 10.3201/eid1602.081727. PMID: 20113553; PMCID: PMC2957990. [^4]: Yaglom H, Rodriguez E, Gaither M, et al. Notes from the Field: Fatal Pneumonic Tularemia Associated with Dog Exposure — Arizona, June 2016. MMWR Morb Mortal Wkly Rep 2017;66:891. DOI: [http://dx.doi.org/10.15585/mmwr.mm6633a5external icon](http://dx.doi.org/10.15585/mmwr.mm6633a5). [^5]: Centers for Disease Control and Prevention (CDC). Tularemia - United States, 2001-2010. MMWR Morb Mortal Wkly Rep. 2013 Nov 29;62(47):963-6. PMID: 24280916; PMCID: PMC4585636. [^6]: Pedati C, House J, Hancock-Allen J, Colton L, Bryan K, Ortbahn D, Kightlinger L, Kugeler K, Petersen J, Mead P, Safranek T, Buss B. Notes from the Field: Increase in Human Cases of Tularemia--Colorado, Nebraska, South Dakota, and Wyoming, January-September 2015. MMWR Morb Mortal Wkly Rep. 2015 Dec 4;64(47):1317-8. doi: 10.15585/mmwr.mm6447a4. Erratum in: MMWR Morb Mortal Wkly Rep. 2016 Jan 8;64(52):1409. PMID: 26632662. [^7]: Feldman KA, Enscore RE, Lathrop SL, Matyas BT, McGuill M, Schriefer ME, Stiles-Enos D, Dennis DT, Petersen LR, Hayes EB. An outbreak of primary pneumonic tularemia on Martha's Vineyard. N Engl J Med. 2001 Nov 29;345(22):1601-6. doi: 10.1056/NEJMoa011374. PMID: 11757506. [^8]: András Lakos, Gyöngyi Nagy, Zsuzsa Kienle, Oculoglandular Tularemia From Crushing an Engorged Tick, _Open Forum Infectious Diseases_, Volume 7, Issue 9, September 2020, ofaa363, [https://doi.org/10.1093/ofid/ofaa363](https://doi.org/10.1093/ofid/ofaa363) [^9]: Larson MA, Fey PD, Hinrichs SH, et al. Francisella tularensis Bacteria Associated with Feline Tularemia in the United States. _Emerging Infectious Diseases_. 2014;20(12):2068-2071. doi:10.3201/eid2012.131101. [^10]: Anne Darmon-Curti, François Darmon, Sophie Edouard, Aurélie Hennebique, Thomas Guimard, Guillaume Martin-Blondel, Timothée Klopfenstein, Jean-Philippe Talarmin, Didier Raoult, Max Maurin, Pierre-Edouard Fournier, Tularemia: A Case Series of Patients Diagnosed at the National Reference Center for Rickettsioses From 2008 to 2017, _Open Forum Infectious Diseases_, Volume 7, Issue 11, November 2020, ofaa440, [https://doi.org/10.1093/ofid/ofaa440](https://doi.org/10.1093/ofid/ofaa440) [^11]:  Whitten T, Bjork J, Neitzel D, Smith K, Sullivan M, Scheftel J. _Notes from the Field:_ Francisella tularensis Type B Infection from a Fish Hook Injury — Minnesota, 2016. MMWR Morb Mortal Wkly Rep 2017;66:194. DOI: [http://dx.doi.org/10.15585/mmwr.mm6607a3external icon](http://dx.doi.org/10.15585/mmwr.mm6607a3). [^12]: Nelson CA, Murua C, Jones JM, et al. Francisella tularensis Transmission by Solid Organ Transplantation, 2017. _Emerging Infectious Diseases_. 2019;25(4):767-775. doi:10.3201/eid2504.181807. [^13]: _Clinical Infectious Diseases_, Volume 69, Issue 5, 1 September 2019, Pages iii–iv, [https://doi.org/10.1093/cid/ciz702](https://doi.org/10.1093/cid/ciz702) [^14]: Birdsell DN, Yaglom H, Rodriguez E, et al. Phylogenetic Analysis of Francisella tularensis Group A.II Isolates from 5 Patients with Tularemia, Arizona, USA, 2015–2017. _Emerging Infectious Diseases_. 2019;25(5):944-946. doi:10.3201/eid2505.180363. [^15]: Rodríguez-Pastor R, Mougeot F, Vidal M, et al. Zoonotic Bacteria in Fleas Parasitizing Common Voles, Northwestern Spain. _Emerging Infectious Diseases_. 2019;25(7):1423-1425. doi:10.3201/eid2507.181646. [^16]: Byington CL, Bender JM, Ampofo K, Pavia AT, Korgenski K, Daly J, Christenson JC, Adderson E. Tularemia with vesicular skin lesions may be mistaken for infection with herpes viruses. Clin Infect Dis. 2008 Jul 1;47(1):e4-6. doi: 10.1086/588843. PMID: 18491968. [^17]: Johansson A, Lärkeryd A, Widerström M, Mörtberg S, Myrtännäs K, Ohrman C, Birdsell D, Keim P, Wagner DM, Forsman M, Larsson P. An outbreak of respiratory tularemia caused by diverse clones of Francisella tularensis. Clin Infect Dis. 2014 Dec 1;59(11):1546-53. doi: 10.1093/cid/ciu621. Epub 2014 Aug 5. PMID: 25097081; PMCID: PMC4650766. [^18]: Weber IB, Turabelidze G, Patrick S, Griffith KS, Kugeler KJ, Mead PS. Clinical recognition and management of tularemia in Missouri: a retrospective records review of 121 cases. Clin Infect Dis. 2012 Nov 15;55(10):1283-90. doi: 10.1093/cid/cis706. Epub 2012 Aug 21. PMID: 22911645. [^19]: Rojas-Moreno C, Bhartee H, Vasudevan A, Adiga R, Salzer W. Tetracyclines for Treatment of Tularemia: A Case Series. Open Forum Infect Dis. 2018 Sep 3;5(9):ofy176. doi: 10.1093/ofid/ofy176. PMID: 30191155; PMCID: PMC6122728. [^20]: Urich SK, Petersen JM. In vitro susceptibility of isolates of Francisella tularensis types A and B from North America. Antimicrob Agents Chemother. 2008 Jun;52(6):2276-8. doi: 10.1128/AAC.01584-07. Epub 2008 Apr 14. PMID: 18411318; PMCID: PMC2415761.