Tularemia in Bulgaria 2003-2004

Radka Komitova,Ivan Ivanov,Rumiana Nenova,Plamen Padeshki,Vassil Popov,Petar Petrov

doi:10.3855/jidc.712

Abstract

Tularemia is an uncommon but potentially fatal zoonosis. А second outbreak of tularemia in Bulgaria, about 40 years after the first, occurred in 1997 in two western regions, near the Serbian border. In 2003 tularemia reemerged in the same foci. This retrospective study aimed to evaluate the clinical characteristics and the efficacy of antibiotic therapy in a tularemia resurgence in the Slivnitza region in 2003-2004. A total of 26 cases were evaluated. Using medical records, the following data were collected for all patients: symptoms, physical signs, and microbiology results of agglutination tests, cultures and PCR assays. Twenty-four of 26 suspected tularemia patients were laboratory confirmed by agglutination test and/or culture. Fifteen (57.7%) patients had clinical presentation compatible with oropharyngeal, 8 (30.8%) with glandular, and 3 (11.5%) with oculoglandular tularemia. The most frequent symptoms were swollen neck (84.6%) and sore throat (76.9%). Lymphadenopathy (100%) was the most common finding. Francisella tularensis (F. tularensis) was detected by PCR, providing a definitive diagnosis in 82.3% of the cases. All the patients were treated with antibiotics considered effective against F. tularensis; however, therapeutic failure was observed in 23.1% of the cases, which was related to a delay in the initiation of antibiotics. The tularemia outbreak in west Bulgaria near the Serbian border was probably food-borne, associated with a surge in the rodent population. The oropharyngeal form was the most common. Although the disease runs a benign course, late initiation of antimicrobial therapy might delay complete recovery.

Highlights

Tularemia is an uncommon but potentially fatal zoonosis
Twenty-six suspected tularemia cases were admitted to the Infectious Diseases Department, University Hospital Saint Anna, Sofia, Bulgaria, between March 2003 and November 2004
Clinical diagnosis Oropharyngeal tularemia was defined as the presence of pharyngitis or tonsillitis and cervical lymphadenopathy in a patient from an endemic region (Slivnitza), who had no response to ß-lactam antibiotics despite at least 10 days of therapy

Summary

Introduction

А second outbreak of tularemia in Bulgaria, about 40 years after the first, occurred in 1997 in two western regions, near the Serbian border. Fifteen (57.7%) patients had clinical presentation compatible with oropharyngeal, 8 (30.8%) with glandular, and 3 (11.5%) with oculoglandular tularemia. All the patients were treated with antibiotics considered effective against F. tularensis; therapeutic failure was observed in 23.1% of the cases, which was related to a delay in the initiation of antibiotics. Tularemia, caused by Francisella tularensis (F. tularensis), is an uncommon but potentially fatal zoonosis in the northern hemisphere. Tularemia is divided into six types: ulceroglandular, glandular, oculoglandular, oropharyngeal, typhoidal, and pneumonic tularemia. While ulceroglandular tularemia occurs more frequently, oropharyngeal infection has increasingly been reported recently in Turkey and in other European countries, including Bulgaria [5,6,7]

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Conclusion