Consensus statement ularemia, a bacterial zoono

Figure 1. Cervical Lymphadenitis in a Patient With Pharyngeal Tularemia

Patient has marked swelling and fluctuant suppura- tion of several anterior cervical nodes. Infection was acquired by ingestion of contaminated food or wa- ter. Source: World Health Organization.

MANAGEMENT OF TULAREMIA AS A BIOLOGICAL WEAPON

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(Reprinted) JAMA, June 6, 2001—Vol 285, No. 21 2767

tions of systemic illness. Inhalational exposures, however, commonly result in an initial clinical picture of systemic illness without prominent signs of res- piratory disease.7,43,53,56 The earliest pulmonary radiographic findings of inhalational tularemia may be peri- bronchial infiltrates, typically advanc- ing to bronchopneumonia in 1 or

more lobes, and often accompanied by pleural effusions and hilar lymphade- nopathy (FIGURE 2).72,75 Signs may, however, be minimal or absent, and some patients will show only 1 or sev- eral small, discrete pulmonary infil- trates or scattered granulomatous lesions of lung parenchyma or pleura. Although volunteers challenged with aerosols of virulent F tularensis (type A) regularly developed systemic symp- toms of acute illness 3 to 5 days fol- lowing exposure, only 25% to 50% of participants had radiological evidence of pneumonia in the early stages of infection.7,26 On the other hand, pul- monary infection can sometimes rap- idly progress to severe pneumonia, respiratory failure, and death.72,80 Lung abscesses occur infrequently.75

Typhoidal tularemia is used to de-

scribe systemic illness in the absence of signs indicating either site of inocu- lation or anatomic localization of in- fection. This should be differentiated from inhalational tularemia with pleu- ropneumonic disease.54,75

Tularemia sepsis is potentially se-

vere and fatal. As in typhoidal tulare- mia, nonspecific findings of fever, ab- dominal pain, diarrhea, and vomiting may be prominent early in the course of illness. The patient typically ap- pears toxic and may develop confu- sion and coma. Unless treated promptly, septic shock and other complications of systemic inflammatory response syn- drome may ensue, including dissemi- nated intravascular coagulation and bleeding, acute respiratory distress syn-

drome, and organ failure.80