Tularemia pneumonia

Suggested Alternatives for Differential Diagnosis Abdominal aneurysm, aortic dissection, pleural effusion, subarachnoid hemorrhage, superior vena cava syndrome, hantavirus pulmonary syndrome, mediastinitis, fulminate mediastinal tumors pneumonia, gastroenteritis, meningitis, ecthyma, rat bite fever, spider bite, leprosy, plague, tularemia, coccidioidomycosis, diphtheria, glanders, histoplasmosis, psittacosis, typhoid fever, and rickettsial pox. 

Suggested Alternatives for Differential Diagnosis Brucellosis, chlamydial pneumonias, infective endocarditis, legionnaires disease, mycoplasma infections, pneumonia, Cox-iella burnetii infection, Francisella tularensis infection, Q fever, tuberculosis, tularemia, typhoid fever, and all atypical pneumonia. 

Suggested Alternatives for Differential Diagnosis Hepatitis, Legionnaires disease, myocarditis, pericarditis, cardiac tamponade, pneumonia, ehrlichiosis, relapsing fever, Rocky Mountain spotted fever, and tularemia. 

Suggested Alternatives for Differential Diagnosis Acute respiratory distress syndrome, congestive heart failure, pulmonary edema, AIDS, pneumonia, cardiogenic shock, septic shock, phosgene toxicity, phosphine toxicity, salicylate toxicity with pulmonary edema, influenza, plague, tularemia, and anthrax. 

Differential Diagnosis An epidemic of inhalation anthrax in its early stage with nonspecific symptoms could be confused with a number of viral, bacteria, and fungal infections. Progression over two to three days with sudden development of severe respiratory distress followed by shock and death within twenty-four to thirty-six hours in essentially all untreated cases eliminates diagnosis other than inhalation anthrax. Other diagnosis to consider would include aerosol exposure to staphylococcal enterotoxin B (SEB), plague, or tularemia pneumonia. 

Differential Diagnosis Q fever usually presents as an undifferentiated febrile illness, or a primary atypical pneumonia, which must be differentiated from pneumonia caused by mycoplasm, Tegionnaires disease, psittacosis or Chlamydia pneumoniae. More rapidly progressive forms of pneumonia may look like bacterial pneumonia including tularemia or plague. 

Caution Tularemia has long been a weapon of war used and/or studied by the Japanese, the Russians, and the United States. Chemoprophylaxis is not recommended following potential natural exposures (tick bite, and/or rabbit or other animal exposures). Inhalation tularemia can lead to fulminant pneumonia with a case fatality rate of 30 to 60 percent without treatment. 

Francisella tularensis is very infectious. A small number (10-50 or so organisms) can cause disease. If F. tularensis were used as a weapon, the bacteria would likely be made airborne for exposure by inhalation. People who inhale an infectious aerosol would generally experience severe respiratory illness, including life-threatening pneumonia and systemic infection, if they are not treated. The bacteria that cause tularemia occur widely in nature and could be isolated and grown in quantity in a laboratory, although manufacturing an effective aerosol weapon would require considerable sophistication. 

Pneumonia, particularly with exposure to typhoidal tularemia... 

BUBONIC PLAGUE tularemia, anthrax, diphtheria, pneumonia, DIG... 

Plague pneumonia is almost always fatal if treatment is not initiated within 24 hours of the onset of symptoms. A number of readily available, broad-spectrum antibiotics have shown efficacy. Specific broad-spectrum antibiotics are also recommended for post-exposure treatment against tularemia and Q fever. A licensed trivalent equine antitoxin available from CDC is the only approved therapy for airborne botulism. 

Tularemia pneumonia can result from an inhalation exposure or from hematogenous spread of the infection. An aerosol release could be expected to result in large numbers of patients experiencing systemic symptoms accompanied by signs and symptoms associated with one or more of the following conditions pharyngitis, bronchiolitis, pleuropneumonitis and hilar lymphadenitis (43). However, many people with inhalational exposure will likely develop a clinical presentation of systemic symptoms without prominent signs or symptoms of respiratory disease. 

Given its rarity, physicians and hospital laboratorians have a low index of suspicion for tularemia infection. Because of the nonspecific symptoms and absence of radiographic findings, physicians and public health authorities would have difficulty distinguishing between a terrorist attack involving tularemia and a natural outbreak of community acquired infection, especially influenza and some atypical pneumonias (43). Several epidemiologic clues that might indicate an intentional cause would include (43) ... 

Congestive heart failure Myocardial infarction Phosgene poisoning Plague Pneumonia Pulmonary embolism Q fever Tularemia... 

Figure 3. Punch-holed disease plate for card-sorting machine. Note that the disease sample for the patent application is TULAREMIA AND TULAREMIA PNEUMONIA, how a Category A weapon of bioterrorism.

Pulmonary syndrome Pneumonia, respiratory insufficiency, Respiratory distress Anthrax, Tularemia, Plague, Psittacosis, Q fever, Histoplasmosis, Coccidiodomycosis, Influenza, Omsk hemorrhagic fever, Crimean-Congo hemorrhagic fever, Korean hemorrhagic fever, Ricin, Staphlococcus enterotoxin B, Botulinum toxin... 

The typhoidal form of tularemia usually causes smaller lymph nodes but there is no skin sore. Both the forms of the disease can develop into pneumonia, shortness of breath and chest pain. 

Tularemia is a zoonosis caused by the Gramnegative, facultative intracellular bacterium, Francisella tularensis. The disease is characterized by fever, localized skin or mucous membrane ulceration, regional lymphadenopathy, and, occasionally, pneumonia. 

Pharyngitis may occur in up to 25% of patients with tularemia.13 22 47 48 The posterior pharynx may not be inflamed however, there may be erythema, exudate, petechiae, hemorrhage, or ulcers. On occasion, patients with pharyngitis may also develop a retropharyngeal abscess or suppuration of regional lymph nodes.47 49-51 Pneumonia commonly accompanies pharyngitis, perhaps reflecting acquisition of the disease by the aerosol route. 

Fig. 24-2. Chest roentgenogram of tularemia pneumonia showing bilateral infiltrates. Photograph Courtesy of William Beisel, M.D., Colonel, Medical Corps, US Army (Ret).

Westerman EL, McDonald J. Tularemia pneumonia mimicking Legionnaire s disease Isolation of organisms on CYE agar and successful treatment with erythromycin. South Med J. 1983 76 1169-1171. 

Fowler J, Taylor R, Gelfand M. Tularemia pneumonia—Tennessee. MMWR. 1983 32 262-263. 

Halstead CC, Kulasinghe HP. Tularemia pneumonia in urban children. Pediatrics. 1978 61 660-662. 

Depending on the route of exposure, the tularemia bacteria may cause skin ulcers, swollen and painful lymph glands, inflamed eyes, sore throat, oral ulcers, or pneumonia. If the bacteria were inhaled, symptoms would include the abrupt onset of fever, chills, headache, muscle aches, joint pain, dry cough, and progressive weakness. Persons with pneumonia can develop chest pain, difficulty breathing, bloody sputum, and respiratory failure. 40% or more of persons with the... 

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