October 1^st, 2005 - Washington, DC

Key Questions to Help Identify the First High-Risk  Patients with Tularemia

See also: Tularemia Identification Flowchart

I. Are there any clinical findings of an illness associated with tularemia such as:

A.       Fever

B.       Cough, shortness of break, difficulty breathing on exertion

C.      Pharyngitis or conjunctivitis, cervical or pre-auricular adenopathy

D.      Unexplained skin ulcers or other lesions

E.       Chest X-ray or Chest CT scan:  Key findings include hilar

            adenopathy that sometimes can cause mediastinal widening, and pleural 

            effusions, in addition to pneumonia.

If “Yes” to the above question, then:

II.  Is there an Epidemiological Linkto the reported detection zone of the tularemia-causing bacteria close to the Mall on September 24-25, “in and near the area between the US Capitol and Lincoln Memorial”? (Wash Post Saturday, Oct 1^st. p. B01)?

III. Were cultures obtained before antibiotics and was a commercial identification  

       system used by the microbiology lab to identify any bacteria growing in culture?

A.        All cultures (blood, sputum, pleural fluid, skin lesions, other) should be done BEFORE any antibiotics are given. If antibiotics are given before cultures, then notify the microbiology lab so they can keep the cultures for 7 days instead of the usual 5 days that CDC recommends allowing the fastidious Francisella tularensis organism to grow. (P.6 of 13. CDC Basic Protocols for Level A Labs for the presumptive identification of F. tularensis.)

B.       “Identification of F. tularensis should not be attempted with commercial identification systems because of the potential for generating aerosols and the high probability of misidentification” (CDC Basic Protocol as above).  The two bacteria typically misidentified by commercial microbiology lab systems when Francisella tularensis is actually present are Actinobacillus actinomycetemcomitans and Haemophilus influenza.

“High Risk” Patients with Tularemia could be defined as those with:

A.       A positive Epidemiological-Link to the known detection zone of tularemia September 24-25, AND any one of the following

1.  Pneumonia with hilar adenopathy (including “mediastinal widening”) or  

    pleural effusions, or other clinical syndromes caused by tularemia as listed.

2. A gram-negative bacteria growing from blood, sputum, pleural effusion, skin

     lesion or other site that has been identified as either:

a.        Actinobacillus actinomycetemcomitansor

b.       Haemophilus influenza.

Conclusion:

The rationale for rapidly identifying and reporting the first patient with tularemia is to establish that an infectious exposure did in fact occur. Thus, there may be additional patients. These patients may already be in hospitals (EDs, ICUs, ward units, or morgues, in outpatient clinics, or they may enter the healthcare system in the coming hours-days. 

Recognition and notification of the appropriate authorities of the first patients with tularemia will facilitate the rapid medical care and public health management of other patients.

Daniel R. Lucey, MD, MPH

Director, Center for Biologic Counterterrorism and Emerging Diseases

ER One Institutes, Washington Hospital Center,

Adjunct Professor of Microbiology and Immunology

Georgetown University School of Medicine

Washington, DC

email: Daniel.R.Lucey@Medstar.net.   Website: www.BePast.org