Tularemia Presenting as a Painless Ulcer with Fever

1Children's Hospital of Philadelphia, Philadelphia, PA
2Children's Hospital of Philadelphia, Philadelphia, PA
3Children's Hospital of Philadelphia, Philadelphia, PA

Meeting: Hospital Medicine 2008, April 3-5, San Diego, Calif.

Abstract number: 157

Case Presentation:

A 14‐year‐old man presented with a 3‐week history of nightly fevers and a painless upper back ulcer. The lesion had grown in size despite oral antibiotics after initial culture revealed MSSA. Review of symptoms included abdominal pain, nausea, chills, myalgias, and a 6‐kg weight loss. The patient denied trauma, joint pain, anorexia, cough, emesis, diarrhea, recent travel, or tick bites. The patient lived in a wooded area with no pets, although several friends owned dogs, cats, and a rabbit. Physical exam revealed a non‐tender upper back ulcer with raised erythematous edges, prominent bilateral cervical and axillary lymphadenopathy, and a 2‐cm nontender left supraclavicular lymph node. Laboratory results revealed normal CBC, liver enzymes, renal function tests, and LDH, uric acid, angiotensin‐converting enzyme, and lysozyme levels. Tuberculin skin testing was negative, as were blood cultures, and serology for Lyme, B. henselae, H. capsulatum, blastomycosis, and HIV. Cultures from biopsies of the skin lesion and supraclavicular lymph node grew Francisella tularensis in 72 hours.

Figure 1. Ulcerated plaque on right upper back.


Tularemia is an uncommon zoonotic infection caused by the highly infectious gram‐negative coccobacillus Francisella tularensis. With approximately 120 cases per year in the United States (in all states except Hawaii), major sources of human infection include ticks and rabbits. There are no recorded cases of human‐to‐human transmission, although laboratory workers are at significant risk of the inhalational form of the disease. Clinical manifestations include the ulceroglandular form (most common), in which a slow healing ulcer is associated with inflamed regional lymph nodes. Other syndromes include glandular, oculoglandular, oropharyngeal, typhoidal, intestinal, and pneumonic forms. Fever, chills, myalgia, and headache are common, as are a variety of skin lesions ranging from nonspecific rashes to ulcerative lesions. Because of tularemia's relative infrequency and nonspecific presenting symptoms, there is often considerable delay in diagnosis and initiation of effective therapy. Diagnosis is usually based on tissue culture, PCR, direct fluorescent antibody, or seroconversion 2‐7 weeks after exposure. Intravenous gentamicin is the most effective treatment in pediatric populations, although fluoroquinolones may offer similar efficacy with less toxicity. With no direct exposure to an infected mammal, the most likely route of infection for this patient in a tick‐endemic area would be from an unrecognized tick bite.


We have described a case of ulceroglandular tularemia, most likely from the bite of an infected tick. Even in the absence of direct exposure to traditionally recognized mammalian carriers, this uncommon but treatable condition should remain a diagnostic consideration by pediatric and adult hospitalists.

Author Disclosure:

L. Zaoutis, none; J. J. Lasa, none; S. Black, none.

To cite this abstract:

Lasa J, Stephanie B, Zaoutis L. Tularemia Presenting as a Painless Ulcer with Fever. Abstract published at Hospital Medicine 2008, April 3-5, San Diego, Calif. Abstract 157. Journal of Hospital Medicine. 2008; 3 (suppl 1). https://www.shmabstracts.com/abstract/tularemia-presenting-as-a-painless-ulcer-with-fever/. Accessed May 26, 2019.

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