Tularemia

Last updated
Tularemia
SynonymsTularaemia, Pahvant Valley plague, [1] rabbit fever, [1] deer fly fever, Ohara's fever [2]
Tularemia lesion.jpg
A tularemia lesion on the back of the right hand
Specialty Infectious disease
Symptoms Fever, skin ulcer, large lymph nodes [3]
Causes Francisella tularensis (spread by ticks, deer flies, contact with infected animals) [4]
Diagnostic method Blood tests, microbial culture [5]
Prevention Insect repellent, wearing long pants, rapidly removing ticks, not disturbing dead animals [6]
Medication Streptomycin, gentamicin, doxycycline, ciprofloxacin [5]
PrognosisGenerally good with treatment [4]
Frequency~200 cases per year (US) [7]

Tularemia, also known as rabbit fever, is an infectious disease caused by the bacterium Francisella tularensis . [4] Symptoms may include fever, skin ulcers, and enlarged lymph nodes. [3] Occasionally, a form that results in pneumonia or a throat infection may occur. [3]

<i>Francisella tularensis</i> species of bacterium

Francisella tularensis is a pathogenic species of Gram-negative coccobacillus, an aerobic bacterium. It is non-spore forming, non-motile and the causative agent of tularemia, the pneumonic form of which is often lethal without treatment. It is a fastidious, facultative intracellular bacterium which requires cysteine for growth. Due to its low infectious dose, ease of spread by aerosol, and high virulence, F. tularensis is classified as a Tier 1 Select Agent by the U.S. government, along with other potential agents of bioterrorism such as Yersinia pestis, Bacillus anthracis and Ebola virus. When found in nature, Francisella tularensis can survive for several weeks at low temperatures in animal carcasses, soil, and water. In laboratory, F. tularensis appears as small rods, and is grown best at 35-37°C.

Fever common medical sign characterized by elevated body temperature

Fever, also known as pyrexia and febrile response, is defined as having a temperature above the normal range due to an increase in the body's temperature set point. There is not a single agreed-upon upper limit for normal temperature with sources using values between 37.5 and 38.3 °C. The increase in set point triggers increased muscle contractions and causes a feeling of cold. This results in greater heat production and efforts to conserve heat. When the set point temperature returns to normal, a person feels hot, becomes flushed, and may begin to sweat. Rarely a fever may trigger a febrile seizure. This is more common in young children. Fevers do not typically go higher than 41 to 42 °C.

Lymphadenopathy disorder of lymph nodes

Lymphadenopathy or adenopathy is disease of the lymph nodes, in which they are abnormal in size, number, or consistency. Lymphadenopathy of an inflammatory type is lymphadenitis, producing swollen or enlarged lymph nodes. In clinical practice, the distinction between lymphadenopathy and lymphadenitis is rarely made and the words are usually treated as synonymous. Inflammation of the lymphatic vessels is known as lymphangitis. Infectious lymphadenitis affecting lymph nodes in the neck is often called scrofula.

Contents

The bacterium is typically spread by ticks, deer flies, or contact with infected animals. [4] It may also be spread by drinking contaminated water or breathing in contaminated dust. [4] It does not spread directly between people. [8] Diagnosis is by blood tests or cultures of the infected site. [5] [9]

Tick order of arachnids

Ticks are small arachnids, typically 3 to 5 mm long, part of the order Parasitiformes. Along with mites, they constitute the subclass Acari. Ticks are ectoparasites, living by feeding on the blood of mammals, birds, and sometimes reptiles and amphibians. Ticks had evolved by the Cretaceous period, the most common form of fossilisation being immersed in amber. Ticks are widely distributed around the world, especially in warm, humid climates.

Deer fly genus of insects

Deer flies are bloodsucking insects considered pests to humans and cattle. They are large flies with large brightly-coloured compound eyes, and large clear wings with dark bands. They are larger than the common housefly and smaller than the horse-fly. There are 250 species of deer fly in the genus Chrysops. Their distribution is worldwide, though they have not been reported in Iceland, Greenland, and Hawaii.

Prevention is by using insect repellent, wearing long pants, rapidly removing ticks, and not disturbing dead animals. [6] Treatment is typically with the antibiotic streptomycin. [9] Gentamicin, doxycycline, or ciprofloxacin may also be used. [5]

Insect repellent substance which repels insects

An insect repellent is a substance applied to skin, clothing, or other surfaces which discourages insects from landing or climbing on that surface. Insect repellents help prevent and control the outbreak of insect-borne diseases such as malaria, Lyme disease, dengue fever, bubonic plague, river blindness and West Nile fever. Pest animals commonly serving as vectors for disease include insects such as flea, fly, and mosquito; and the arachnid tick.

Streptomycin An antibiotic effective against various gram-positive and gram-negative bacteria

Streptomycin is an antibiotic used to treat a number of bacterial infections. This includes tuberculosis, Mycobacterium avium complex, endocarditis, brucellosis, Burkholderia infection, plague, tularemia, and rat bite fever. For active tuberculosis it is often given together with isoniazid, rifampicin, and pyrazinamide. It is given by injection into a vein or muscle.

Gentamicin chemical compound

Gentamicin, sold under brand name Garamycin among others, is an antibiotic used to treat several types of bacterial infections. This may include bone infections, endocarditis, pelvic inflammatory disease, meningitis, pneumonia, urinary tract infections, and sepsis among others. It is not effective for gonorrhea or chlamydia infections. It can be given intravenously, by injection into a muscle, or topically. Topical formulations may be used in burns or for infections of the outside of the eye. In the developed world, it is often only used for two days until bacterial cultures determine what specific antibiotics the infection is sensitive to. The dose required should be monitored by blood testing.

Between the 1970s and 2015, around 200 cases are reported in the United States a year. [7] Males are affected more often than females. [7] It occurs most frequently in the young and the middle aged. [7] In the United States, most cases occur in the summer. [7] The disease is named after Tulare County, California, where the disease was discovered in 1911. [10] A number of other animals, such as rabbits, may also be infected. [4]

Tulare County, California County in California, United States

Tulare County is a county in the U.S. state of California. As of the 2010 census, the population was 442,179. Its county seat is Visalia. The county is named for Tulare Lake, once the largest freshwater lake west of the Great Lakes. Drained for agricultural development, the site is now in Kings County, which was created in 1893 from the western portion of the formerly larger Tulare County.

Rabbit Mammals of the family Leporidae

Rabbits are small mammals in the family Leporidae of the order Lagomorpha. Oryctolagus cuniculus includes the European rabbit species and its descendants, the world's 305 breeds of domestic rabbit. Sylvilagus includes 13 wild rabbit species, among them the 7 types of cottontail. The European rabbit, which has been introduced on every continent except Antarctica, is familiar throughout the world as a wild prey animal and as a domesticated form of livestock and pet. With its widespread effect on ecologies and cultures, the rabbit is, in many areas of the world, a part of daily life—as food, clothing, a companion, and as a source of artistic inspiration.

Signs and symptoms

Depending on the site of infection, tularemia has six characteristic clinical variants: ulceroglandular (the most common type representing 75% of all forms), glandular, oropharyngeal, pneumonic, oculoglandular, and typhoidal. [11]

The incubation period for tularemia is one to 14 days; most human infections become apparent after three to five days. [12] In most susceptible mammals, the clinical signs include fever, lethargy, loss of appetite, signs of sepsis, and possibly death. Nonhuman mammals rarely develop the skin lesions seen in people. Subclinical infections are common, and animals often develop specific antibodies to the organism. Fever is moderate or very high, and tularemia bacilli can be isolated from blood cultures at this stage. The face and eyes redden and become inflamed. Inflammation spreads to the lymph nodes, which enlarge and may suppurate (mimicking bubonic plague). Lymph node involvement is accompanied by a high fever.

Anorexia (symptom) medical symptom

Anorexia is the decreased sensation of appetite. While the term in non-scientific publications is often used interchangeably with anorexia nervosa, many possible causes exist for a decreased appetite, some of which may be harmless, while others indicate a serious clinical condition or pose a significant risk.

Sepsis life-threatening organ dysfunction triggered by infection

Sepsis is a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. Common signs and symptoms include fever, increased heart rate, increased breathing rate, and confusion. There may also be symptoms related to a specific infection, such as a cough with pneumonia, or painful urination with a kidney infection. In the very young, old, and people with a weakened immune system, there may be no symptoms of a specific infection and the body temperature may be low or normal, rather than high. Severe sepsis is sepsis causing poor organ function or insufficient blood flow. Insufficient blood flow may be evident by low blood pressure, high blood lactate, or low urine output. Septic shock is low blood pressure due to sepsis that does not improve after fluid replacement.

Subclinical infection

A subclinical infection is an infection that, being subclinical, is nearly or completely asymptomatic. A subclinically infected person is thus an asymptomatic carrier of a microbe, intestinal parasite, or virus that usually is a pathogen causing illness, at least in some individuals. Many pathogens spread by being silently carried in this way by some of their host population. Such infections occur both in humans and nonhuman animals. An example of an asymptomatic infection is a mild common cold that is not noticed by the infected individual. Since subclinical infections often occur without eventual overt sign, their existence is only identified by microbiological culture or DNA techniques such as polymerase chain reaction.

Cause

Tularemia is caused by the bacteria Francisella tularensis which is typically spread by ticks, deer flies, contact with infected animals. [4]

Bacteria

Chocolate agar culture showing Francisella tularensis colonies Chocolate agar 1.jpg
Chocolate agar culture showing Francisella tularensis colonies
Another culture of Francisella tularensis Francisella tularensis 01.jpg
Another culture of Francisella tularensis

The bacteria can penetrate into the body through damaged skin, mucous membranes, and inhalation. Humans are most often infected by tick/deer fly bite or through handling an infected animal. Ingesting infected water, soil, or food can also cause infection. Hunters are at a higher risk for this disease because of the potential of inhaling the bacteria during the skinning process. It has been contracted from inhaling particles from an infected rabbit ground up in a lawnmower (see below). Tularemia is not spread directly from person to person. [13] Humans can also be infected through bioterrorism attempts. [14]

Francisella tularensis can live both within and outside the cells of the animal it infects, meaning it is a facultative intracellular bacterium. [15] It primarily infects macrophages, a type of white blood cell, and thus is able to evade the immune system. The course of disease involves the spread of the organism to multiple organ systems, including the lungs, liver, spleen, and lymphatic system. The course of disease is different depending on the route of exposure. Mortality in untreated (before the antibiotic era) patients has been as high as 50% in the pneumoniac and typhoidal forms of the disease, which however account for less than 10% of cases. [16]

Spread

The most common way the disease is spread is via arthropod vectors. Ticks involved include Amblyomma , Dermacentor , Haemaphysalis , and Ixodes . [17] Rodents, rabbits, and hares often serve as reservoir hosts, [18] but waterborne infection accounts for 5 to 10% of all tularemia in the United States. [19] Tularemia can also be transmitted by biting flies, particularly the deer fly Chrysops discalis. Individual flies can remain infectious for 14 days and ticks for over two years.[ citation needed ] Tularemia may also be spread by direct contact with contaminated animals or material, by ingestion of poorly cooked flesh of infected animals or contaminated water, or by inhalation of contaminated dust. [20]

Diagnosis

Pathology

In lymph node biopsies, the typical histopathologic pattern is characterized by geographic areas of necrosis with neutrophils and necrotizing granulomas. The pattern is non specific and similar to other infectious lymphadenopathies. [21]

The laboratorial isolation of F. tularensis requires special media such as buffered charcoal yeast extract agar. It cannot be isolated in the routine culture media because of the need for sulfhydryl group donors (such as cysteine). The microbiologist must be informed when tularemia is suspected not only to include the special media for appropriate isolation, but also to ensure that safety precautions are taken to avoid contamination of laboratory personnel.

Serological tests (detection of antibodies in the serum of the patients) are available and widely used. Cross reactivity with Brucella can confuse interpretation of the results, so diagnosis should not rely only on serology. Molecular methods such as PCR are available in reference laboratories.

Prevention

There are no safe, available, approved vaccines against tularemia. However, vaccination research and development continues, with live attenuated vaccines being the most thoroughly researched and most likely candidate for approval. [22] Sub-unit vaccine candidates, such as killed-whole cell vaccines, are also under investigation, however research has not reached a state of public use. [22]

Optimal preventative practices include limiting direct exposure when handling potentially infected animals by wearing gloves and face masks (importantly when skinning deceased animals). [23]

Treatment

If infection occurs or is suspected, treatment is generally with the antibiotics streptomycin or gentamicin. [23] Doxycycline was previously used. [24] Gentamicin may be easier to obtain than streptomycin. [24] There is also tentative evidence to support the use of quinolone antibiotics. [24]

Prognosis

Since the invention of antibiotics, the rate of death associated with tularemia has decreased from 60% to less than 4%. [23]

Epidemiology

Tularemia is most common in the Northern Hemisphere, including North America and parts of Europe and Asia. [23] It occurs between 30º and 71º north latitude. [23]

In the United States, although records show that tularemia was never particularly common, incidence rates continued to drop over the course of the 20th century. Between 1990 and 2000, the rate dropped to less than 1 per one million, meaning the disease is extremely rare in the United States today. [25]

In Europe, tularemia is generally rare, though outbreaks with hundreds of cases occur every few years in neighboring Finland and Sweden. [26] In Sweden over a period from 1984–2012 a total of 4,830 cases of tularemia occurred (most of the infections were acquired within the country). About 1.86 cases per 100,000 persons occur each year with higher rates in those between 55 and 70. [27]

Outbreaks

From May to October 2000, an outbreak of tularemia in Martha's Vineyard, Massachusetts, resulted in one fatality, and brought the interest of the United States Centers for Disease Control and Prevention (CDC) as a potential investigative ground for aerosolised Francisella tularensis. For a time, Martha's Vineyard was identified as the only place in the world where documented cases of tularemia resulted from lawn mowing. [28] However, in May 2015 [29] a resident of Lafayette, Colorado, died from aerosolised F. tularensis, which was also connected to lawn mowing, highlighting this new vector of risk.

An outbreak of tularemia occurred in Kosovo in 1999-2000. [30]

In 2004, three researchers at Boston Medical Center, in Massachusetts, were accidentally infected with F. tularensis, after apparently failing to follow safety procedures. [31]

In 2005, small amounts of F. tularensis were detected in the National Mall area of Washington, D.C., the morning after an antiwar demonstration on September 24, 2005. Biohazard sensors were triggered at six locations surrounding the Mall. While thousands of people were potentially exposed, no infections were reported. The detected bacteria likely originated from a natural source, not from a bioterror attempt. [32]

In 2005, an outbreak occurred in Germany amongst participants in a hare hunt. About 27 people came into contact with contaminated blood and meat after the hunt. Ten of the exposed, aged 11 to 73, developed tularemia. One of these died due to complications caused by chronic heart disease. [33]

Tularemia is endemic in the Gori region of the Eurasian country of Georgia. The last outbreak was in 2006. [34] The disease is also endemic on the uninhabited Pakri Islands off the northern coast of Estonia. Used for bombing practice by Soviet forces, chemical and bacteriological weapons may have been dropped on these islands. [35]

In July 2007, an outbreak was reported in the Spanish autonomous region of Castile and León and traced to the plague of voles infesting the region. Another outbreak had taken place ten years before in the same area. [36]

In January 2011, researchers searching for brucellosis among feral pig populations in Texas discovered widespread tularemia infection or evidence of past infection in feral hog populations of at least two Texas counties, even though tularemia is not normally associated with pigs at all. Precautions were recommended for those who hunt, dress, or prepare feral hogs. Since feral hogs roam over large distances, concern exists that tularemia may spread or already be present in feral hogs over a wide geographic area. [37]

In November 2011, it was found in Tasmania. Reports claimed it to be the first in the Southern Hemisphere. [38] However, the causative organism was documented to have been isolated from a foot wound in the Northern Territory in 2003. [39]

In 2014, at least five cases of tularemia were reported in Colorado and at least three more cases in early 2015, including one death as a result of lawn mowing, as noted above. [29] In the summer of 2015, a popular hiking area just north of Boulder was identified as a site of animal infection and signs were posted to warn hikers.[ citation needed ]

History

Ancient

It has been suggested that F. tularensis was the cause of human outbreaks in ancient Canaan in about 1715 BC and in 1075 BC. [40] The same author has proposed the following scenario: a long-lasting epidemic that plagued the eastern Mediterranean in the 14th century BC can also traced back to a focus in Canaan along the Arwad-Euphrates trading route. This epidemic contaminated an area stretching from Cyprus to Iraq, and from Palestine to Syria, sparing Egypt (due to a quarantine) and Anatolia (owing to effective political boundaries). Subsequently, wars spread the same disease into central Anatolia, from whence it was deliberately introduced into western Anatolia. If this scenario is true, it would constitute the first known record of biological warfare. [41] Finally, Aegean soldiers fighting in western Anatolia returned home to their Greek islands, further spreading the same epidemic.

Modern

The tularemia bacterium was first isolated by G.W. McCoy of the United States Public Health Service plague lab and reported in 1912. [42] [43] Scientists determined tularemia could be dangerous to humans; a human being may catch the infection after contacting an infected animal. The ailment soon became associated with hunters, cooks and agricultural workers. [44]

Biological weapon

The Centers for Disease Control and Prevention (CDC) regard F. tularensis as a viable biological warfare agent, and it has been included in the biological warfare programs of the United States, Soviet Union and Japan at various times. [45] A former Soviet biological weapons scientist, Ken Alibek, has alleged that an outbreak of tularemia among German soldiers shortly before the Battle of Stalingrad was due to the release of F. tularensis by Soviet forces. Others who have studied the pathogen "propose that an outbreak resulting from natural causes is more likely". [46] [47] In the United States, practical research into using rabbit fever as a biological warfare agent took place in 1954 at Pine Bluff Arsenal, Arkansas, an extension of the Fort Detrick program. [48] It was viewed as an attractive agent because:

  • it is easy to aerosolize
  • it is highly infective; between 10 and 50 bacteria are sufficient to infect victims
  • it is nonpersistent and easy to decontaminate (unlike anthrax)
  • it is highly incapacitating to infected persons
  • it has comparatively low lethality, which is useful where enemy soldiers are in proximity to noncombatants, e.g. civilians

The Schu S4 strain was standardized as "Agent UL" for use in the United States M143 bursting spherical bomblet. It was a lethal biological warfare agent with an anticipated fatality rate of 40 to 60%. The rate-of-action was around three days, with a duration-of-action of one to three weeks (treated) and two to three months (untreated), with frequent relapses. UL was streptomycin resistant. The aerobiological stability of UL was a major concern, being sensitive to sunlight, and losing virulence over time after release. When the 425 strain was standardized as "agent JT" (an incapacitant rather than lethal agent), the Schu S4 strain's symbol was changed again to SR.[ citation needed ]

Both wet and dry types of F. tularensis (identified by the codes TT and ZZ) were examined during the "Red Cloud" tests, which took place from November 1966 to February 1967 in the Tanana Valley, Alaska. [49]

Other animals

Cats and dogs can acquire the disease from the bite of a tick or flea that has fed on an infected host, such as a rabbit or rodent. For treatment of infected cats, antibiotics are the preferred treatment, including tetracycline, chloramphenicol or streptomycin. Long treatment courses may be necessary as relapses are common. [50]

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Classification
D
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