Baylor University Medical Center Proceedings April 2017 - 176

a

b

c

Figure. Cross-sectional CT shows pulmonary nodules (arrows) in the (a) left upper lobe measuring 1 cm, (b) right upper lobe measuring 1.3 cm, and (c) left lower
lobe measuring 1.6 cm.

confusion. Pulmonary tularemia is a subacute or chronic infection that presents with fever, cough, weight loss, and mediastinal
lymphadenopathy that mimics tuberculosis, lymphoma, or sarcoidosis (6). A distinctive feature of this case is that the patient
was on immunosuppressive therapy for rheumatoid arthritis,
which placed him at a higher risk for typhoidal tularemia than
an average individual. This is an atypical presentation for tularemia because the patient presented with nonspecific symptoms
and was found to have incidental pulmonary nodules on CT
scan of the chest.
Blood cultures are usually falsely negative because F. tularensis
is a fastidious organism that requires cysteine-enriched media,
and the laboratory must be made aware of its possibility ahead
of time. Serology with agglutination or enzyme-linked immunosorbent assay can be used for diagnosis with titers of 1:128
or 1:160. Antibodies may not be detectable until the second
week of illness (7). Streptomycin is usually the drug of choice
but is not readily available in most hospitals. Streptomycin and

176

gentamicin have 97% and 86% cure rates, respectively, against
F. tularensis (6).
1.

2.
3.
4.
5.
6.
7.
8.

McCoy GW, Chapin CW. Further observations on a plague-like disease of
rodents with a preliminary note on the causative agent Bacterium tularense.
J Infect Dis 1912;10(1):61-72.
Thomas LD, Schaffner W. Tularemia pneumonia. Infect Dis Clin North
Am 2010;24(1):43-55.
Francis E. A summary of the present knowledge of tularemia. Medicine
1928;7(4):411-432.
Centers for Disease Control and Prevention. Tularemia statistics. Available
at http://www.cdc.gov/tularemia/statistics/; accessed November 2, 2016.
Evans ME, Gregory DW, Schaffner W, McGee ZA. Tularemia: a 30-year
experience with 88 cases. Medicine (Baltimore) 1985;64(4):251-269.
Maurin M, Pelloux I, Brion JP, Del Banõ J-N, Picard A. Human tularemia
in France, 2006-2010. Clin Infect Dis 2011;53(10):e133-e141.
Koskela P, Salminen A. Humoral immunity against Francisella tularensis
after natural infection. J Clin Microbiol 1985;22(6):973-979.
Enderlin G, Morales L, Jacobs RF, Cross JT. Streptomycin and alternative
agents for the treatment of tularemia: review of the literature. Clin Infect
Dis 1994;19(1):42-47.

Baylor University Medical Center Proceedings

Volume 30, Number 2



http://www.cdc.gov/tularemia/statistics/

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