Rosen & Barkin's 5-Minute Emergency Medicine Consult (735 page)
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Authors: Jeffrey J. Schaider,Adam Z. Barkin,Roger M. Barkin,Philip Shayne,Richard E. Wolfe,Stephen R. Hayden,Peter Rosen
Tags: #Medical, #Emergency Medicine
BOOK: Rosen & Barkin's 5-Minute Emergency Medicine Consult
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- Pneumonia, Adult
- Bronchiectasis
- Coccidiomycosis
- Histoplasmosis
- Lymphoma
- Pneumocystis carinii
Pneumonia - Pulmonary Embolism
- Sarcoidosis
CODESICD9
- 010.90 Primary tuberculous infection, unspecified, unspecified
- 011.90 Unspecified pulmonary tuberculosis, unspecified
- 795.51 Nonspecific reaction to tuberculin skin test without active tuberculosis
ICD10
TULAREMIA- A15.7 Primary respiratory tuberculosis
- A15.9 Respiratory tuberculosis unspecified
- R76.11 Nonspecific reaction to skin test w/o active tuberculosis
Scott Bentz
BASICSDESCRIPTION
- Tularemia is an acute febrile illness caused by the small aerobic gram-negative pleomorphic intracellular
coccobacillus Francisella tularensis
:- Organism is highly infectious.
- Person-to-person transmission has not been reported.
- Organism is highly infectious.
- Humans become infected through different environmental exposures:
- Bites from infected tick, deerfly, mosquito, or other infected insect
- Direct contact with infectious animal tissue or fluid
- Contact with or ingestion of contaminated food, water, or soil
- Inhalation of infected aerosols (e.g., cutting grass with power mowers, which may aerosolize the organism)
- Bites from infected tick, deerfly, mosquito, or other infected insect
- The 4 major strains of the bacterium have different virulence and geographic location:
- 2 subspecies cause human infection in North America:
F. tularensis
subspecies tularensis (type A, more virulent) and
F. tularensis
subspecies holartica (type B, less virulent)
- 2 subspecies cause human infection in North America:
- Natural hosts:
- Lagomorphs and other rodents
- Found in species of wild animals (insects, rabbits, hares, ticks, flies, muskrats, beavers, mice), domestic animals (sheep, cattle, cats), ticks, and water and soil contaminated by infected animals
- Lagomorphs and other rodents
- Natural vectors:
- Ticks
- Biting flies
- Mosquitoes
- Wild rabbits
- Ticks
- Weaponization of tularemia was accomplished during the Cold War:
- Because of its virulence and ability to be aerosolized, it remains a potential biologic agent for mass destruction.
- Because of its virulence and ability to be aerosolized, it remains a potential biologic agent for mass destruction.
- Lab technicians handling culture specimens are at high risk:
- F. tularensis
cultures should be manipulated only in a biosafety level 3 facility.
- F. tularensis
- Also known as “rabbit fever” or “deerfly fever”
- Individuals who spend time outdoors in endemic areas are at higher risk:
- Farmers
- Hunters
- Forest workers
- Those who handle animal carcasses are at highest risk (taxidermists and butchers).
- Two-thirds of cases occur in males.
- Farmers
- Although tularemia can occur worldwide, it is endemic in the northern hemisphere:
- Reported nationwide except in Hawaii
- States with the highest incidence include Missouri, Arkansas, Kansas, South Dakota, and Oklahoma.
- Few hundred cases annually in US, although probably underreported
- Peak season is June–October.
- Reported nationwide except in Hawaii
- Mortality is 5–15%. Appropriately treated patients have mortality as low as 1%.
- 25% of cases occur in children 1–14 yr of age.
- Children who spend time outdoors in endemic rural areas are at highest risk.
DIAGNOSISSIGNS AND SYMPTOMS
- Tularemia has different presentations based on route of entry:
- Primary route of entry is through skin; most often a cutaneous ulcer develops.
- Primary route of entry is through skin; most often a cutaneous ulcer develops.
- Incubation is 3–5 days, range 1–14 days. Lesion usually begins as papule, often with fever.
- 6 forms of illness:
- Ulceroglandular:
- Most common presentation (70–80% of cases)
- Inoculated cutaneously (scratch, abrasion, insect bite) with as few as 50 organisms
- Initially, a local cutaneous papule at point of entry
- Followed by tender regional adenopathy and constitutional symptoms to include fever, chills, myalgias, and headaches
- Associated with pneumonia in 30% of cases
- Most common presentation (70–80% of cases)
- Glandular:
- Rare form
- Gains access to lymphatic system or bloodstream through inapparent abrasion
- Tender regional lymphadenopathy with no local lesions
- Rare form
- Oculoglandular:
- Rare form
- Organism enters through a splash of infected blood/fluid to the eye or is introduced by eye rubbing after handling infectious materials (e.g., rabbit carcass).
- Edema, conjunctivitis, injection, chemosis with periauricular, submandibular, or cervical lymphadenopathy
- Rare form
- Pharyngeal:
- Rare form
- From ingestion of contaminated food or water
- Severe throat pain with exudative pharyngitis and regional lymphadenitis
- Rare form
- Pneumonic:
- Secondary to inhalation
- Seen in sheep shearers, farmers, landscapers, and lab technicians
- Fever, dry cough, and pleuritic chest pain develop.
- Pneumonia can occur in 30% of patients with ulceroglandular tularemia
- Secondary to inhalation
- Typhoidal:
- Historically, the typhoidal form defined as devoid of skin or mucous membrane lesion or remarkable lymph node enlargement.
- No known point of entry (probably oral or respiratory).
- Only when no route of infection can be established may the term still be acceptable.
- In North America, where type A is prevalent, fulminant manifestations are reported, including severe sepsis, meningitis, endocarditis, hepatic failure, and renal failure.
- Septicemia associated with type A tularemia is usually extremely severe and potentially fatal. High fever, abdominal pain, and diarrhea may occur early in the course of disease.
- Historically, the typhoidal form defined as devoid of skin or mucous membrane lesion or remarkable lymph node enlargement.
- Ulceroglandular:
- Exposure and epidemiologic risk factors can be helpful.
- Sudden fever, chills, headaches
- Progression of components of signs and symptoms may be useful in defining form of illness.
- Fever
- Tender, well-demarcated cutaneous ulcer
- Tender regional lymphadenopathy; lymph nodes can develop fluctuance and spontaneously drain.
- Exudative pharyngitis (with pharyngeal tularemia)
- Ulcerations of the conjunctiva with pronounced chemosis (with oculoglandular tularemia)
Lab
- No rapid diagnostic test available
- Routine lab studies nonspecific:
- CBC can be normal.
- ESR might be slightly elevated.
- CSF: May have increased protein or mild pleocytosis
- LFTs are often abnormal.
- CBC can be normal.
- Gram stain, cultures, and tissue biopsies:
- Often negative
- Often negative
- Blood cultures usually negative because of specific growth requirements
- Enzyme-linked immunosorbent assay and polymerase chain reaction are available through reference labs.
- Serum antibody titers:
- Typically do not reach diagnostic levels until ≥10 days after the onset of illness
- A single titer of at least 1:160 for tube agglutination is diagnostic for
F. tularensis
infection. - May not be elevated before day 11 of illness and generally are diagnostic after 16th day.
- Typically do not reach diagnostic levels until ≥10 days after the onset of illness
- Chest radiograph for:
- Consolidative process, pleural effusions, and hilar adenopathy
- Consolidative process, pleural effusions, and hilar adenopathy
- CT scan of chest for:
- Severe pulmonary symptoms
- Other possible etiologies of atypical pneumonia
- Severe pulmonary symptoms
- Ulceroglandular tularemia mimics include:
- Tuberculosis
- Catscratch disease
- Syphilis
- Chancroid
- Lymphogranuloma venereum
- Toxoplasmosis
- Sporotrichosis
- Rat-bite fever
- Anthrax
- Tuberculosis
- Oculoglandular tularemia mimics include:
- Adenoviral infection
- Adenoviral infection
- Pharyngeal tularemia mimics include:
- Diphtheria
- Bacterial pharyngitis
- Infectious mononucleosis
- Adenoviral infection
- Diphtheria
- Typhoidal tularemia mimics include:
- Salmonellosis
- Brucellosis
- Legionnaire disease
- Q fever
- Malaria
- Disseminated fungal or mycobacterial infections
- Salmonellosis
- Pulmonary tularemia mimics include:
- Mycoplasmal infection
- Legionnaire disease
- Chlamydial infection
- Tuberculosis
- Mycoplasmal infection
TREATMENTOther books
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