Tularemia is a potentially severe zoonotic disease caused by Francisella tularensis. A lack of awareness about tularemia can be embarrassing and could result in delayed treatment because of improper diagnosis. The diagnosis of tularemia is difficult, because the infections are rare and the clinical spectrum is broad. As only 1 adult case has been reported in Korea thus far, pediatricians in Korea may be unfamiliar with tularemia. We report our experience with a 14-year-old male adolescent with tularemia who presented with atypical pneumonia and possible infective endocarditis. Although the infectivity and mortality rates for tularemia are very high if left untreated, we did not suspect tularemia in this case until the incidental isolation of F. tularensis. The present case suggests that clinicians in Korea should be more aware of tularemia. This case also suggests that tularemia should be considered in undetermined cases of atypical pneumonia or acute febrile illness without local signs.
Adolescent ; Adult ; Diagnosis ; Endocarditis* ; Francisella tularensis ; Humans ; Korea* ; Mortality ; Pediatrics ; Pneumonia* ; Tularemia* ; Zoonoses

Tularemia is a high-risk infectious disease caused by Gram-negative bacterium Francisella tularensis. Due to its high fatality at very low colony-forming units (less than 10), F. tularensis is considered as a powerful potential bioterrorism agent. Vaccine could be the most efficient way to prevent the citizen from infection of F. tularensis when the bioterrorism happens, but officially approved vaccine with both efficacy and safety is not developed yet. Research for the development of tularemia vaccine has been focusing on the live attenuated vaccine strain (LVS) for long history, still there are no LVS confirmed for the safety which should be an essential factor for general vaccination program. Furthermore the LVS did not show protection efficacy against high-risk subspecies tularensis (type A) as high as the level against subspecies holarctica (type B) in human. Though the subunit or recombinant vaccine candidates have been considered for better safety, any results did not show better prevention efficacy than the LVS candidate against F. tularensis infection. Currently there are some more trials to develop vaccine using mutant strains or nonpathogenic F. novicida strain, but it did not reveal effective candidates overwhelming the LVS either. Difference in the protection efficacy of LVS against type A strain in human and the low level protection of many subunit or recombinant vaccine candidates lead the scientists to consider the live vaccine development using type A strain could be ultimate answer for the tularemia vaccine development.
Bioterrorism ; Communicable Diseases ; Francisella tularensis ; Humans ; Sprains and Strains ; Stem Cells ; Tularemia ; Vaccination ; Vaccines

The level of terrorist threats using chemical, biological, and radiological agents has been continuously increasing, and it is an undeniable truth that these agents are actually in use today. The fact that most chemical, biological, and radiological agents cause skin-related symptoms, and that the skin symptoms are observed at a relatively early stage of the condition, leads to the conclusion that dermatologists could be the first point of contact for potential victims of these agents. It is highly important that first responders are able to recognize symptoms caused by these agents early and react quickly. Therefore, dermatologists do have a responsibility to take on a role in dealing with chemical, biological, and radiological attacks, and pre-equip themselves with professional knowledge in this field. Among the various types of chemical agents, typical examples of agents causing skin-related symptoms are blistering agents, which lead to bullae and necrosis on the skin. Biological agents are classified from Category A to C according to their respective risk factors. The most dangerous Category A agents include anthrax, smallpox, plague, tularemia, and viral hemorrhagic fever, all of which are known to show characteristic skin-related symptoms. Upon exposure to a certain level of radiation, radiological agents can also lead to erythema on the skin. In this article, we will discuss various characteristics and up-to-date treatment methods of potential chemical, biological, and radiological agents to help dermatologists advance their knowledge in this field.
Anthrax ; Biological Factors ; Blister ; Erythema ; Hemorrhagic Fevers, Viral ; Necrosis ; Plague ; Risk Factors ; Skin ; Smallpox ; Terrorism ; Tularemia ; Weapons

The level of terrorist threats using chemical, biological, and radiological agents has been continuously increasing, and it is an undeniable truth that these agents are actually in use today. The fact that most chemical, biological, and radiological agents cause skin-related symptoms, and that the skin symptoms are observed at a relatively early stage of the condition, leads to the conclusion that dermatologists could be the first point of contact for potential victims of these agents. It is highly important that first responders are able to recognize symptoms caused by these agents early and react quickly. Therefore, dermatologists do have a responsibility to take on a role in dealing with chemical, biological, and radiological attacks, and pre-equip themselves with professional knowledge in this field. Among the various types of chemical agents, typical examples of agents causing skin-related symptoms are blistering agents, which lead to bullae and necrosis on the skin. Biological agents are classified from Category A to C according to their respective risk factors. The most dangerous Category A agents include anthrax, smallpox, plague, tularemia, and viral hemorrhagic fever, all of which are known to show characteristic skin-related symptoms. Upon exposure to a certain level of radiation, radiological agents can also lead to erythema on the skin. In this article, we will discuss various characteristics and up-to-date treatment methods of potential chemical, biological, and radiological agents to help dermatologists advance their knowledge in this field.
Anthrax ; Biological Factors ; Blister ; Erythema ; Hemorrhagic Fevers, Viral ; Necrosis ; Plague ; Risk Factors ; Skin ; Smallpox ; Terrorism ; Tularemia ; Weapons

OBJECTIVES: Earthquakes are one the most common natural disasters that lead to increased mortality and morbidity from transmissible diseases, partially because the rodents displaced by an earthquake can lead to an increased rate of disease transmission. The aim of this study was to evaluate the prevalence of plague and tularemia in rodents in the earthquake zones in southeastern Iran. METHODS: In April 2013, a research team was dispatched to explore the possible presence of diseases in rodents displaced by a recent earthquake magnitude 7.7 around the cities of Khash and Saravan in Sistan and Baluchestan Province. Rodents were trapped near and in the earthquake zone, in a location where an outbreak of tularemia was reported in 2007. Rodent serums were tested for a serological survey using an enzyme-linked immunosorbent assay. RESULTS: In the 13 areas that were studied, nine rodents were caught over a total of 200 trap-days. Forty-eight fleas and 10 ticks were obtained from the rodents. The ticks were from the Hyalomma genus and the fleas were from the Xenopsylla genus. All the trapped rodents were Tatera indica. Serological results were negative for plague, but the serum agglutination test was positive for tularemia in one of the rodents. Tatera indica has never been previously documented to be involved in the transmission of tularemia. CONCLUSIONS: No evidence of the plague cycle was found in the rodents of the area, but evidence was found of tularemia infection in rodents, as demonstrated by a positive serological test for tularemia in one rodent.
Agglutination Tests ; Disasters ; Earthquakes* ; Enzyme-Linked Immunosorbent Assay ; Iran* ; Mortality ; Plague* ; Prevalence ; Rodentia* ; Serologic Tests ; Siphonaptera ; Ticks ; Tularemia* ; Xenopsylla

Out of 60 national communicable diseases in Korea, 23 are zoonoses, diseases transmissible from animals to humans. Among the bacterial zoonoses, plague, brucellosis, anthrax, Q fever, tularemia, glanders, and melioidosis are categorized as a high-level threat of bioterrorism and biowarfare in the world. In this paper, the trends of notifiable bacterial zoonoses recently occurring or recurring in Korea and other potential pathogens for bioterrorism or biowarfare are reviewed. Notifiable bacterial zoonoses recently occurring in Korea are enterohemorrhagic Escherichia coli (EHEC) infection, tetanus, tuberculosis, scrub typhus, leptospirosis, brucellosis, and anthrax. Other bacterial diseases recently emerging are tularemia, ehrlichiosis, and Q fever. However, no human case of plague, glanders, and melioidosis has been reported yet.
Animals ; Anthrax ; Bioterrorism ; Brucellosis ; Communicable Diseases ; Communicable Diseases, Emerging ; Ehrlichiosis ; Enterohemorrhagic Escherichia coli ; Glanders ; Humans ; Korea ; Leptospirosis ; Melioidosis ; Plague ; Q Fever ; Scrub Typhus ; Tetanus ; Tuberculosis ; Tularemia ; Zoonoses*

The aim of this study was to investigate the source and the size of a tularemia outbreak in a village located in a non-endemic area. Five patients from the same village were admitted to hospital with the same complaints all within one week of September 2001. Tularemia was suspected and a diagnosis was made after physical and anamnesis examinations. The village was visited the same week that the patients were admitted to the hospital, in the January and April 2002. The villagers were examined and screened serologically by microagglutination method and the water sources were investigated bacteriologically. A total of 14 people were found to be infected from the outbreak and the oropharyngeal form was the only clinical presentation. Antibody titers ranged between 1 : 80 and 1 : 640. The patients responded well to the aminoglycoside plus tetracycline therapy. Examination of the pipewater and three springs revealed that all the water sources were contaminated by coliforms, however, Francisella tularensis could not be isolated in glucose-cystine medium. Antibody levels stayed stable or decreased seven months after. Tularemia had not been reported in this area before, so the first patients were misdiagnosed. In conclusion tularemia should be considered in differential diagnosis of patients with fever, sore throat and cervical lymphadenopaties.
Adolescent ; Adult ; Aged ; Animals ; Child ; *Disease Outbreaks ; Female ; Human ; Male ; Middle Aged ; Rats ; Seasons ; Seroepidemiologic Studies ; Tularemia/*epidemiology/*transmission ; Turkey/epidemiology ; Water Supply

OBJECTIVES: Tularemia is a zoonotic disease transmitted by direct contact with infected animals and through arthropod bites, inhalation of contaminated aerosols, ingestion of contaminated meat or water, and skin contact with any infected material. It is widespread throughout the northern hemisphere, including Iran and its neighbors to the north, northeast, and northwest. METHODS: In this paper, the epidemiology of tularemia as a re-emerging infectious disease in the world with a focus on Iran and the neighboring countries is reviewed. RESULTS: In Iran, positive serological tests were first reported in 1973, in wildlife and domestic livestock in the northwestern and southeastern parts of the country. The first human case was reported in 1980 in the southwest of Iran, and recent studies conducted among at-risk populations in the western, southeastern, and southwestern parts of Iran revealed seroprevalences of 14.4, 6.52, and 6%, respectively. CONCLUSIONS: Several factors may explain the absence of reported tularemia cases in Iran since 1980. Tularemia may be underdiagnosed in Iran because Francisella tularensis subspecies holarctica is likely to be the major etiological agent and usually causes mild to moderately severe disease. Furthermore, tularemia is not a disease extensively studied in the medical educational system in Iran, and empirical therapy may be effective in many cases. Finally, it should be noted that laboratories capable of diagnosing tularemia have only been established in the last few years. Since both recent and older studies have consistently found tularemia antibodies in humans and animals, the surveillance of this disease should receive more attention. In particular, it would be worthwhile for clinical researchers to confirm tularemia cases more often by isolating F. tularensis from infected humans and animals.
Aerosols ; Animals ; Antibodies ; Arthropods ; Bacterial Infections ; Communicable Diseases, Emerging* ; Eating ; Epidemiology ; Francisella tularensis ; Humans ; Inhalation ; Iran* ; Livestock ; Meat ; Rodentia ; Seroepidemiologic Studies ; Serologic Tests ; Skin ; Tularemia* ; Water ; Zoonoses

PURPOSE: Tularemia is an infection caused by Francisella tularensis. Its diagnosis and treatment may be difficult in many cases. The aim of this study was to evaluate treatment modalities for pediatric tularemia patients who do not respond to medical treatment. METHODS: A single-center, retrospective study was performed. A total of 19 children with oropharyngeal tularemia were included. RESULTS: Before diagnosis, the duration of symptoms in patients was 32.15±17.8 days. The most common lymph node localization was the cervical chain. All patients received medical treatment (e.g., streptomycin, gentamicin, ciprofloxacin, and doxycycline). Patients who had been given streptomycin, gentamicin, or doxycycline as initial therapy for 10–14 days showed no response to treatment, and recovery was only achieved after administration of oral ciprofloxacin. Response to treatment was delayed in 5 patients who had been given ciprofloxacin as initial therapy. Surgical incision and drainage were performed in 9 patients (47.5%) who were unresponsive to medical treatment and were experiencing abcess formation and suppuration. Five patients (26.3%) underwent total mass excision, and 2 patients (10.5%) underwent fine-needle aspiration to reach a conclusive differential diagnosis and inform treatment. CONCLUSION: The causes of treatment failure in tularemia include delay in effective treatment and the development of suppurating lymph nodes.
Biopsy, Fine-Needle ; Child ; Ciprofloxacin ; Diagnosis ; Diagnosis, Differential ; Doxycycline ; Drainage ; Francisella tularensis ; Gentamicins ; Humans ; Lymph Nodes ; Retrospective Studies ; Streptomycin ; Suppuration ; Treatment Failure ; Tularemia

Tularemia is a major laboratory acquired zoonoses caused by Francisella tularensis that have high virulence, and usually transmitted to humans from direct contact with infected wild animals like rabbits or insect vectors like ticks. Clinical tularemia can be divided with 6 major syndromes that are delineated by the mode of organism aquisition, in which ulceroglandular type is the most common. F. tularensis have 3 different biogroups which have homogeneous antigenecity, type A (biogroup tularensis), type B (biogroup palearctica) and biogroup novicida, and can be confirmed by serology most frequently. In the domestic area, there was no reports of tularemia in humans or presence of bacteria in the reservoirs. Authers experienced a case of tularemia which is suspected as F. tularensis type B, ulceroglandular type. A healthy 40-year-old man admitted the hospital for lymph node swelling in both axillary and upper arm area and for furuncles in both forearm and palm. He contacted with dead rabbit and eated it after cooking before 20 days from admission day. In laboratory cultures, F. tularensis did not grow in any of the routine or anaerobic culture media except for one blood agar plate at 5 days. After subculturing that to cystine containing chocolate agar plate at 37C degree, 5% CO2 incubator, we could see the accelerating growth of colony. In microbiological test, it was oxidase and urease negative. In acid production in cystine trypticase agar base, it was glucose positive and sucrose, maltose, glycerol negative. In agglutinating test, F. tularensis antiserum titer (Difco, USA) with isolates was 1:160 or over and antibody titer to F. tularensis antigen (Difco, USA) was 1:320 or over. Anti-F. tularensis-IF assay and Anti-F. tularensis-indirect-EIA with isolates were positive.
Adult ; Agar ; Animals ; Animals, Wild ; Arm ; Bacteria ; Cacao ; Cooking ; Culture Media ; Cystine ; Forearm ; Francisella tularensis* ; Francisella* ; Furunculosis ; Glucose ; Glycerol ; Humans ; Incubators ; Insect Vectors ; Lymph Nodes ; Maltose ; Oxidoreductases ; Rabbits ; Sucrose ; Ticks ; Tularemia* ; Urease ; Virulence ; Zoonoses