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SWELLING IN A
TEENAGER
Karin Lammert, PGY-3
HPI
■ 15yo previously healthy female transferred from RTU for failure to improve on multiple
antibiotics
■ 1 month ago: lump behind her left ear; resolved spontaneously
■ 1 week ago: lump behind L ear returned, along with new tenderness and fevers
– Also had a scabbed lesion on her left scalp which her sister lanced
■ PCP started augmentin
■ After 5 days on augmentin, fevers persisted, presented to ED
– CBC normal, neck CT with diffuse subcutaneous edema = cellulitis; no abscess or
mastoiditis
– Started on PO Keflex, Bactrim, discharged home
HPI, continued
■ ??
Diagnosis
■ June 10: started PO Cipro for empiric treatment of tularemia, sent Tularemia IgG and
IgM, Tularemia PCR swab from draining lesion, ID consulted
■ Alerted lab since F. tularensis is a biohazard if grown in the lab
■ Repeat head/neck CT (at the start of cipro treatment) showed improvement in
periauricular inflammation, no occult abscess or infection
TULAREMIA,
A.K.A. RABBIT FEVER
Tularemia
■ Anaerobic gram-negative bacteria Francisella tularensis, highly infectious
■ Transmission:
– Skin contact with infected animals (rabbits, rodents, cats)
– Bites from infected insects (ticks, deer flies)
– Ingestion or inhalation of contaminated water, dust or aerosols (especially
agricultural)
■ Most common in the south central US but cases have been reported in all states
except Hawaii. Most cases occur in rural regions and in summer months.
■ The average incubation period is 3-5 days following infection, with onset of
nonspecific symptoms including malaise, fever, decreased appetite, vomiting,
fatigue, muscle aches, and headache.
Reported cases
of Tularemia
Source: CDC
Reported cases
of Tularemia
Cases in 2016
Tularemia types
1. Ulceroglandular (most common): central eschar and skin ulceration at the site where
the bacteria entered the body, along with tender regional lymphadenopathy.
2. Glandular tularemia has lymph node swelling but no skin involvement.
3. Oculoglandular occurs when bacteria enter the eye and presents with conjunctivitis
and regional lymphadenopathy.
4. Oropharyngeal--Ingestion of contaminated food or water (more common outside of the
United States), causing sore throat, exudative pharyngitis, tonsillitis, mouth ulcers, and
cervical lymphadenopathy.
5. Pneumonic tularemia is the most severe, with dominant pulmonary infection caused
by primary inhalation of contaminated aerosols, or secondary spread of bacteria to
lungs in the bloodstream if the primary source of infection is left untreated.
6. Typhoidal tularemia presents as fever and generalized symptoms without regional
lymphadenopathy or other localizing signs; it is often difficult to diagnose.
Diagnosis and Treatment
■ F. tularensis DNA by PCR
– Antibody testing is less clinically useful as it can take two weeks for titers to
become reliably positive following an infection, and both IgG and IgM can
remain elevated for years following an infection.
– Gram-stain and routine cultures of blood or infected tissues are rarely positive.
■ Early treatment is essential; any suspected cases should be treated empirically
without waiting for confirmatory diagnostic testing.
■ For moderate to severe disease, the preferred agents are aminoglycosides—
streptomycin in adults and gentamycin for children, intravenously, for 7-10 days.
■ In milder cases, oral doxycycline and ciprofloxacin may be used for a 14-day course
of outpatient treatment. Doxycycline is associated with a higher relapse rate.
■ Surgical management may be necessary for drainage of suppurative lymph nodes or
empyemas.
Patient course
■ Discharged on clindamycin to treat presumed group A streptococcus cellulitis, and
ciprofloxacin for possible tularemia.
– At the time of discharge she had downtrending C-reactive protein, improvement
in fevers, and was feeling better.
■ The day after discharge, tularemia PCR confirmed the diagnosis of ulceroglandular
tularemia. Cultures of the wound finalized negative for aerobic bacteria, fungi, and
acid-fast bacilli.
■ Continued on ciprofloxacin and completed a 14-day course of clindamycin with
healing of her scalp lesion and no further fevers.
■ About two weeks after discharge, she developed increasing neck pain; CT scan
identified large necrotic mass in her post-auricular region that required resection by
ENT. Intraoperative wound cultures were negative.
■ She continued on ciprofloxacin for an additional 5 weeks post-operatively (total two
months duration) with full healing of ear wound and return to her normal state of
health.