Should the chronic form of tularemia be defined? Should the treatment of the chronic form be managed differently?

Abstract

Background: Tularemia is a bacterial, zoonotic disease caused by Francisella tularensis . Although the ulceroglandular form is the most common form in the world, oropharyngeal tularemia is the most common form in Turkey . Lymph node suppuration is the most common complication. F. tularensis causes granulomatous and suppurative lesions in the lymph nodes and other organs. Methods: Seventeen suspected oropharyngeal form tularemia cases complicated with suppurated lymphadenitis have been examined in this study. All of the patients (17, 100%) had cervical lymphadenopathies and had a history of beta-lactam antibiotic use with the diagnosis of tonsillitis. Tularemia cases were diagnosed according to the case definition of World Health Organization (WHO). Results: All of the patients (17, 100%) had cervical lymphadenopathies ranging in size from 2-8 cm and unilateral lymphadenopathy, while 12 (71%) patients had right-sided lymphadenopathy. The rate of fever was 41% and the rate of pharyngitis or tonsillitis was 52% at presentation. All patients had a history of beta-lactam antibiotic use with the diagnosis of tonsillitis. Seven patients recovered with first-line monotherapy. In the remaining 10 patients, treatment was rearranged, and these patients were switched to combination treatment or another anti-infective. Surgical drainage was performed on all but two of the patients. Conclusions: The diagnosis of tularemia is often delayed. It may take a significant length of time to diagnose the condition and the disease may become complicated. As it is understood from our study and other studies, the types and duration of treatment can vary and differences can be observed in cases that are past the acute stage. Although the guideline has included a classical treatment approach for the tularemia, there is no standard approach to cases with delayed diagnosis, complicated cases and those refractory to conventional regimens. These observations and other examinations have raised the question whether the chronic form of tularemia should be defined, and whether the treatment options and durations should be re-standardized according to the ‘chronic tularemia’ definition as a ‘chronic granulomatous disease’