Dermatologic manifestations of tularemia: a study of 151 cases in the mid-Anatolian region of Turkey.

Abstract

Tularemia is a serious and potentially life-threatening zoonosis caused by Francisella tularensis, a highly infective, gram-negative coccobacillus. Although there are plenty of case reports and studies of tularemia outbreaks, the literature is lacking in reports on dermatologic manifestations of the disease. This study aimed to identify skin manifestations in clinical forms of tularemia. A total of 151 patients diagnosed with tularemia at Çankırı State Hospital, Çankırı, Turkey, were retrospectively examined. Dermatologic data for these patients were assessed. The most frequent clinical manifestation of tularemia was the glandular form (49.7%), followed by the oropharyngeal, ulceroglandular, and oculoglandular forms (39.1, 6.0, and 5.3%, respectively). Physical manifestations were observed in 64.5% of females and 56.9% of males. Lymphadenopathy and tonsillitis were the most frequent physical findings and were noted in 57.6 and 25.2% of patients, respectively. Erythema multiforme was found in 17 patients (11.3%), most of whom presented with the oropharyngeal and glandular forms, and was followed by ulcer (6.0%), urticaria (3.3%), erythema nodosum (2.6%), and cellulitis (0.7%). However, it should be noted that this study was retrospective and that its patient sample demonstrated four of the six clinical forms of tularemia. Patients with the oropharyngeal form of tularemia had statistically significantly more physical findings than those with other clinical forms of the disease (P<0.001). There were statistically more skin findings in the ulceroglandular form (P<0.001). There was no statistical correlation between serum antibody titers and cutaneous findings (P=0.585). Although the literature reports that skin lesions are observed more frequently in women than in men, we did not find any statistically significant difference between the sexes in any type of skin lesion.