Tularemia Patients Research Articles

Francisella tularensis-specific antibody levels in sera from Swedish patients with suspected tularemia during a 13-year period.

For a majority of tularemia patients, serology is the basis for the diagnosis. The aim of this study was to perform an analysis of the samples analyzed at a Swedish reference laboratory for the presence of Francisella tularensis-specific antibody levels in sera from individuals with suspected tularemia. Annual and monthly variations of the total number of samples and proportions of positive samples were analyzed, as well as the influence of age and gender. We performed a retrospective analysis of the presence of F. tularensis-specific antibodies in serological samples from patients with suspected tularemia analyzed during the period 2010 - 2022 at the University Hospital of Umeå in Sweden, a national reference laboratory, by use of various statistical methods. In total, some 15,100 serum samples had been analyzed for the presence of IgG and IgM antibodies by ELISA during the 13-year period. Overall, there were higher number of samples with IgG positive or borderline titers, 2,522 and 921, respectively, than with IgM positive or borderline titers, 1,802 and 409, respectively. Repeated samples were obtained from some 1,930 individuals and approximately a third of the cases, which were initially seronegative, had seroconverted when resampled. Peak number of monthly samples were recorded in August and September, > 3,000. Annual numbers varied greatly and peak numbers were observed in 2015 and 2019, 1,832 and 2,250, respectively, whereas some other years the numbers were 700 - 800. There was also much variation in the annual and monthly percentages of positive samples and they varied between less than 10% to greater than 20%. The highest percentages of positive samples were recorded in September and October. IgG and IgM titers declined with age and these differences were highly significant for IgG titers, with decreasing average titers for each 20-year interval. Collectively, the data demonstrate the marked annual and seasonal variations in tularemia sampling occurring in Sweden. Also, the proportion of positive samples increased during months and years with peak number of samples. Another notable finding was that average antibody titers decreased with increased age.

Tularemia in the Differential Diagnosis of Lymphadenitis: A Retrospective Analysis of 16 Cases.

Tularemia is a zoonotic disease caused by Francisella tularensis, a gram-negative, facultative, intracellular coccobacillus. It can occur in different clinical forms, and the most common form in our country (Turkey) is the oropharyngeal form. Unfortunately, the diagnosis of lymphadenitis caused by tularemia is delayed unless it is suspected, especially in sporadic cases. Our aim is to remind clinicians to have tularemia amongdifferentials of lymphadenitis. In this study, the clinical and laboratory findings of 16 tularemia patients between 2011 and 2021 were evaluated retrospectively. The mean age of the 16 patients included in the study was 39 years, and 62.5% were female. The patients were diagnosed with tularemia on the average 31st day of their complaints. The rate of use of beta-lactam group antibiotics before diagnosis was 74%. About 81.25% of the patients were engaged in animal husbandry/farming, and living in rural areas (93.75%) and farming (81.25%) were the most common possible risk factors. The patients were admitted to the hospital with the most common complaints of enlarged lymph nodes (100%), fatigue (62.5%) and loss of appetite (56.25%). All patients had lymphadenopathy, and the most common location of lymphadenopathy was the cervical region (81.25%). Moxifloxacin (56.25%) was used most frequently in the treatment of tularemia, and surgical drainage was performed for 31% of the patients. The diagnosis of tularemia is often delayed unless clinical suspicion is high. Delayed diagnosis may lead to unnecessary frequent use of antibiotics, especially beta-lactam group antibiotics. As the diagnosis is delayed, since lymph node suppuration is common, surgical intervention may be required. This situation can cause extra burden for both patients and the health system. It may be beneficial to organize trainings to increase awareness among physicians and society in order to make the diagnosis early.

Muş İlinde Görülen Tularemi Olgularının Retrospektif Değerlendirilmesi: 2011-2022

Objective: Tularemia is a bacterial disease of humans, wild and domestic animals. Recently, an increase in human tularemia cases has been observed in many countries worldwide. This study aimed to calculate the incidence of tularemia cases in Muş, determine the seasonal distribution of cases, and describe the socio-demographic and clinical characteristics of tularemia cases detected over a twelve-year period. Methods: Data from 162 patients diagnosed clinically and serologically with tularemia and admitted to health facilities in Muş province between 2011 and 2022 were retrospectively analysed. Results: In our study, among 162 tularemia patients with F. tularensis microagglutination test titres of 1/160 and above, the ratio of male and female cases was equal (50%), and the mean age was 24.51 years. In the twelve-year evaluation, there were two major epidemics, and the most cases were seen in 2018 with 37 cases. Most cases were observed in winter (38.3%) and autumn (25.3%). Oropharyngeal tularemia was the most common form (64.2%) among the cases evaluated. Similar disease was found in 33.3% of patients living in the same neighbourhood as the patients, and no mortality was observed in any of the patients. Conclusion: As the oropharyngeal form is the most common, contact with contaminated water should be questioned, rodent and tick populations should be monitored and detailed epidemiological studies should be conducted. We believe that hygiene and sanitation measures are important with regard to tularemia outbreaks.

Epizootiological and Epidemiological Situation on Tularemia in the Republic of Karelia

The aim of this study was to assess the epidemiological and epizootiological situation on tularemia in the Republic of Karelia, and to develop a set of preventive (anti-epidemic) measures. Materials and methods. On the basis of statistical observation data, primary medical documentation and literature data, the morbidity of the population, the number of vaccinated persons, the results of laboratory studies of small mammals, arthropods and environmental objects, the species composition of hosts and vectors of infection were assessed. The situation in the republic was compared to the situation in Finland and neighboring regions of Russia. Results and discussion. The incidence of tularemia was registered in the Republic of Karelia in 1950–1971 (52 cases) and in 2010–2020 (121 cases). In the last decade, mainly the ulceroglandular forms have been diagnosed, the urban population predominated among the patients. In all cases, infection was transmitted through mosquito bites, i. e., not associated with professional activities. There are floodplainswamp and forest types of natural foci in the republic. The results of their monitoring are indicative of the activation of the epizootic process, covering almost the entire territory of Karelia. In several areas bordering tularemia disadvantaged areas of Finland and Russia, a high infection rate of rodents was detected, but tularemia patients were not registered. For an adequate assessment of the situation, it is necessary to increase the efficiency of surveying natural foci, study the immune structure of the population and improve the diagnosis of infection. The main areas of preventive (anti-epidemic) measures are vaccination of persons with professional risk of infection and persons living near the activated micro-foci of infection; reduction of the area of fields not used in agriculture; reclamation work, combating landfills, regular removal of waste from the territories of permanent and temporary residence of the population; the use of effective repellents; raising awareness of the population and authorities about the situation, symptoms of the disease, measures of its prevention.

Development of Immunoassays for Detection of Francisella tularensis Lipopolysaccharide in Tularemia Patient Samples.

Francisella tularensis is the causative agent of tularemia, a zoonotic bacterial infection that is often fatal if not diagnosed and treated promptly. Natural infection in humans is relatively rare, yet persistence in animal reservoirs, arthropod vectors, and water sources combined with a low level of clinical recognition make tularemia a serious potential threat to public health in endemic areas. F. tularensis has also garnered attention as a potential bioterror threat, as widespread dissemination could have devastating consequences on a population. A low infectious dose combined with a wide range of symptoms and a short incubation period makes timely diagnosis of tularemia difficult. Current diagnostic techniques include bacterial culture of patient samples, PCR and serological assays; however, these techniques are time consuming and require technical expertise that may not be available at the point of care. In the event of an outbreak or exposure a more efficient diagnostic platform is needed. The lipopolysaccharide (LPS) component of the bacterial outer leaflet has been identified previously by our group as a potential diagnostic target. For this study, a library of ten monoclonal antibodies specific to F. tularensis LPS were produced and confirmed to be reactive with LPS from type A and type B strains. Antibody pairs were tested in an antigen-capture enzyme-linked immunosorbent assay (ELISA) and lateral flow immunoassay format to select the most sensitive pairings. The antigen-capture ELISA was then used to detect and quantify LPS in serum samples from tularemia patients for the first time to determine the viability of this molecule as a diagnostic target. In parallel, prototype lateral flow immunoassays were developed, and reactivity was assessed, demonstrating the potential utility of this assay as a rapid point-of-care test for diagnosis of tularemia.

Analyses of tularemia cases and their long-term results

Tularemia is a zoonotic disease and endemic in the northern hemisphere. The aim of this study was to evaluate the epidemiological, clinical and laboratory characteristics of tularemia patients, and to re-analyze their lymphadenopathy during the follow-up. The patients who were diagnosed with tularemia were reviewed. They were invited for the long term, physical and radiological evaluations. 69.8% patients had lived in rural areas. 54.7% patients were associated with animal husbandry, the 18.9% had contact with rodents. The most common form was the glandular type (62.3%). The frequency of granulomatous lymphadenitis was significantly higher in patients diagnosed later than 30 days from the onset of symptoms. Lymphadenopathy was undetectable in 61.5% patients, its severity was reduced in 38.4% patients compared to its state at the admission. In rural areas, avoiding contact with wild animals can ensure the protection from the pathogen. Public communities should be made aware of the disease.

Early Diagnosis of Tularemia by Flow Cytometry, Czech Republic, 2003-20151.

We retrospectively assessed the utility of a flow cytometry–based test quantifying the percentage of CD3+ T cells with the CD4–/CD8– phenotype for predicting tularemia diagnoses in 64 probable and confirmed tularemia patients treated during 2003–2015 and 342 controls with tularemia-like illnesses treated during 2012–2015 in the Czech Republic. The median percentage of CD3+/CD4–/CD8– T cells in peripheral blood was higher in tularemia patients (19%, 95% CI 17%–22%) than in controls (3%, 95% CI 2%–3%). When we used 8% as the cutoff, this test’s sensitivity was 0.953 and specificity 0.895 for distinguishing cases from controls. The CD3+/CD4–/CD8– T cells increased a median of 7 days before tularemia serologic test results became positive. This test supports early presumptive diagnosis of tularemia for clinically suspected cases 7–14 days before diagnosis can be confirmed by serologic testing in regions with low prevalences of tularemia-like illnesses.

Clinical characteristics in a sentinel case as well as in a cluster of tularemia patients associated with grape harvest

BackgroundTularemia is caused by Francisella tularensis and can occasionally establish foodborne transmission. MethodsPatients were identified by active case detection through contact with the treating physicians and consent for publication was obtained. Clinical data were accumulated through a review of the patient charts. Serology, culture, and PCR methods were performed for confirmation of the diagnosis. Case clusterA 46-year-old patient was hospitalised in the University Hospital Frankfurt (a tertiary care hospital) for pharyngitis and cervical lymphadenitis with abscess. A diagnosis of tularemia was made serologically, but treatment with ciprofloxacin initially failed. F. tularensis was detected in pus from the lymph node using a specific real-time PCR. The use of RD1 PCR led to the identification of the subspecies holarctica. Antibiotic therapy with high-dose ciprofloxacin and gentamicin was administered and was subsequently changed to ciprofloxacin and rifampicin. During a must-tasting, five other individuals became infected with tularemia by ingestion of contaminated must. All patients required treatment durations of more than 14 days. ConclusionsMechanically harvested agricultural products, such as wine must, can be a source of infection, probably due to contamination with animal carcasses. The clinical course of tularemia can be complicated and prolonged and requires differentiated antibiotic treatment.

Coinfections identified from metagenomic analysis of cervical lymph nodes from tularemia patients

BackgroundUnderlying coinfections may complicate infectious disease states but commonly go unnoticed because an a priori clinical suspicion is usually required so they can be detected via targeted diagnostic tools. Shotgun metagenomics is a broad diagnostic tool that can be useful for identifying multiple microbes simultaneously especially if coupled with lymph node aspirates, a clinical matrix known to house disparate pathogens. The objective of this study was to analyze the utility of this unconventional diagnostic approach (shotgun metagenomics) using clinical samples from human tularemia cases as a test model. Tularemia, caused by the bacterium Francisella tularensis, is an emerging infectious disease in Turkey. This disease commonly manifests as swelling of the lymph nodes nearest to the entry of infection. Because swollen cervical nodes are observed from many different types of human infections we used these clinical sample types to analyze the utility of shotgun metagenomics.MethodsWe conducted an unbiased molecular survey using shotgun metagenomics sequencing of DNA extracts from fine-needle aspirates of neck lymph nodes from eight tularemia patients who displayed protracted symptoms. The resulting metagenomics data were searched for microbial sequences (bacterial and viral).ResultsF. tularensis sequences were detected in all samples. In addition, we detected DNA of other known pathogens in three patients. Both Hepatitis B virus (HBV) and Human Parvovirus B-19 were detected in one individual and Human Parvovirus B-19 alone was detected in two other individuals. Subsequent PCR coupled with Sanger sequencing verified the metagenomics results. The HBV status was independently confirmed via serological diagnostics, despite evading notice during the initial assessment.ConclusionOur data highlight that shotgun metagenomics of fine-needle lymph node aspirates is a promising clinical diagnostic strategy to identify coinfections. Given the feasibility of the diagnostic approach demonstrated here, further steps to promote integration of this type of diagnostic capability into mainstream clinical practice are warranted.

Coinfections identified from metagenomic analysis of cervical lymph nodes from tularemia patients

Coinfections identified from metagenomic analysis of cervical lymph nodes from tularemia patients

Evaluation of epidemiologic and clinical features of oropharyngeal tularemia patients in the Eastern Anatolia Region of Turkey

Tularemia is a zoonotic infectious disease caused by Francisella tularensis. Tularemia is endemic in the northern hemisphere and is usually seen in North America, Europe and Asia. Although the ulceroglandular tularemia is the most common form in these regions, the oropharyngeal form is more prevalent in Eastern Europe, including Turkey. The disease has importance in Turkey due to its wide geographic distribution and periodic outbreaks. The aim of this study was to determine the demographic, clinical and epidemiological characteristics of oropharyngeal tularemia patients. The demographic, clinical, epidemiological and laboratory findings of 26 tularemia patients admitted to our hospital from Erzurum and 5 neighbour provinces were analyzed retrospectively. Francisella tularensis microagglutination test (MAT) was performed for all patients whose clinical symptoms were consistent with tularemia and MAT titers ≥ 1/160 were considered positive. Twenty-six oropharyngeal tularemia patients (13 males and 13 females) were included in the study. All of the patients had cervical lymphadenopathy (LAP) at least one month period. Twenty (76.9%) of the patients included in the study were living in rural areas, and 17 (65.4%) were dealing with livestock. It was determined that 9 (34.6%) of the patients used water from municipal water supply, 9 (34.6%) of the patients used water from natural water supply and 8 (30.8%) of the patients used both of the water supplies. The most common symptoms among the patients in the study were fever in 23 (88.5%) patients, sore throat in 24 (92.3%) patients, and cervical LAP in all of the patients. Thirteen (50%) of the patients were treated with streptomycin, 7 (26.9%) with doxycycline and 6 (23.1%) with gentamicin. This is the first study showing that tularemia is present in Erzincan, Ağrı, Iğdır as well as Erzurum provinces, and it provides that the incidence has increased in this region. Tularemia diagnosis is generally underestimated due to the lack of specific symptoms. Therefore, tularemia should also be considered in patients who have complaints of sore throat and cervical LAP in non-endemic regions.

Treatment-failure tularemia in children.

PurposeTularemia is an infection caused by Francisella tularensis. Its diagnosis and treatment may be difficult in many cases. The aim of this study was to evaluate treatment modalities for pediatric tularemia patients who do not respond to medical treatment.MethodsA single-center, retrospective study was performed. A total of 19 children with oropharyngeal tularemia were included.ResultsBefore diagnosis, the duration of symptoms in patients was 32.15±17.8 days. The most common lymph node localization was the cervical chain. All patients received medical treatment (e.g., streptomycin, gentamicin, ciprofloxacin, and doxycycline). Patients who had been given streptomycin, gentamicin, or doxycycline as initial therapy for 10–14 days showed no response to treatment, and recovery was only achieved after administration of oral ciprofloxacin. Response to treatment was delayed in 5 patients who had been given ciprofloxacin as initial therapy. Surgical incision and drainage were performed in 9 patients (47.5%) who were unresponsive to medical treatment and were experiencing abcess formation and suppuration. Five patients (26.3%) underwent total mass excision, and 2 patients (10.5%) underwent fine-needle aspiration to reach a conclusive differential diagnosis and inform treatment.ConclusionThe causes of treatment failure in tularemia include delay in effective treatment and the development of suppurating lymph nodes.

Ultrasonography and contrast-enhanced CT findings of tularemia in the neck

We aimed to evaluate the ultrasonography (US) and contrast-enhanced computed tomography (CECT) findings of tularemia in the neck. US and CECT findings of 58 patients with serologically proven tularemia were retrospectively evaluated. Forty-eight patients underwent US and 42 patients underwent CECT. Lymph node characteristics and parotid preauricular region involvement were analyzed using US and CECT. In addition, involvement of larynx, oropharynx, and retropharynx; presence of periorbital edema; and neck abscess formation were evaluated using CECT. Fine needle aspiration cytology (FNAC) results of enlarged lymph nodes were analyzed in 29 patients. Hypoechoic pattern, round shape, absence of hilum, and cystic necrosis were seen in most of the lymph nodes especially at level 2 and 3 on US and CECT. Matting was more commonly observed than irregular nodal border on US and CECT. Parotid preauricular region involvement was seen in 20.8% of patients on US. Oropharyngeal, retropharyngeal, laryngeal and parotid preauricular region involvement and periorbital edema were seen in 52.4%, 19.1%, 4.8%, 31%, and 9.5% of tularemia patients, respectively. Neck abscess was found in 59.5% of patients on CECT. Suppurative inflammation was the most common finding of FNAC. Tularemia should be considered in the presence of level 2 and 3 lymph nodes with cystic necrosis, matting, absence of calcification, oropharyngeal and retropharyngeal region involvement, and neck abscess, particularly in endemic areas.

Predicting tularemia with clinical, laboratory and demographical findings in the ED

IntroductionWe aimed to determine clinical, laboratory and demographical characteristics of tularemia on admission to Emergency Department (ED). Material and MethodsMedical data of 317 patients admitted to ED and subsequently hospitalized with suspected tularemia between January 1, 2011, and May 31, 2015, were collected. Patients were divided into 2 groups according to microagglutination test results, as tularemia (+) and tularemia (−). ResultsOf the 317 patients involved, 49 were found to be tularemia (+) and 268 were tularemia (−). Mean age of the tularemia (+) patients was found to be higher than that of tularemia (−) patients. When compared to tularemia (−) patients, a significant portion of patients in tularemia (+) patients were elderly, living in rural areas and had contact with rodents. When clinical and laboratory findings of the 2 groups were compared, any statistical significance could not be determined. ConclusionTularemia is a disease of elderly people living in rural areas. Contact with rodents also increases risk of tularemia in suspected patients.

Evaluation of tularemia cases focusing on the oculoglandular form.

Tularemia is a zoonotic disease caused by Francisella tularensis. The oculoglandular form is one of the rarest forms. In this study, evaluated tularemia patients, focusing on the ocular form and the efficacy of early antibiotic therapy. During a tularemia outbreak, the epidemiological and clinical findings, laboratory assays, and drugs used for the treatment of 48 patients were recorded prospectively. The diagnosis of tularemia was confirmed with microagglutination test (MAT) as well as clinical findings. The mean age of the subject was 48.6 years; 23 (47.9%) of them were female. Thirty-six (81.25%) patients had clinical presentation compatible with oropharyngeal tularemia, seven (14.58%) with oculoglandular tularemia, and two (4.1%) with ulceroglandular tularemia. The most common symptoms were fever (91.6%) and sore throat (81.2%), and the most common findings were lymphadenopathy (91.6%) and tonsillopharyngitis (81.2%). In the oculoglandular form, fever, lymphadenopathy, periorbital edema, conjunctival injection, and chemosis were found. The most distinctive ophthalmic feature was follicular conjunctivitis and conjunctival epithelial defects. Forty-five cases had positive serological results with MAT. All the patients were treated with antibiotics considered effective against F. tularensis, and topical antimicrobial treatment was given to the patients with oculoglandular tularemia. Twenty-six (54.16%) patients, who were admitted within three weeks of the onset of symptoms, recovered without sequel. During tularemia outbreaks, ocular involvement should be considered carefully. The early administration of appropriate treatment will be more effective in resolving the infection and preventing complications. Along with systemic antibiotic therapy, topical treatment will help recovery.

New anti-infective strategies for treatment of tularemia

New anti-infective strategies for treatment of tularemia

Evaluation of clinical and sonographic features in 55 children with tularemia.

The aim of this study was to determine the clinical characteristics and sonographic features of lymphadenopathy (LAP) and to evaluate the treatment modalities and treatment outcomes in children with tularemia. Demographic characteristics, ultrasonographic and physical examination findings, and treatment outcomes in 55 tularemia patients (24 male and 31 female) with a mean age of 10.8 ± 4.0 years were analyzed retrospectively. Lymph node necrosis was classified in three stages based on ultrasound findings-stage 1, cortical microabscesses; stage 2, cortical and medullar abscesses; stage 3, total necrosis of the lymph node. In total, 50 (90%) of the patients had oropharyngeal, four (8%) had glandular, and one (2%) had oculoglandular tularemia. The most common symptoms were sore throat (67%) and fever (64%). LAP was the most frequently (100%) observed sign. Abscess formation was noted in 36 (65%) patients, of which seven (19%) were sonographically classified as stage 1, 20 (55%) as stage 2, and nine (26%) as stage 3. There was a statistically significant correlation between delayed treatment and stage of abscess formation in lymph nodes (p<0.05). Treatment failure was observed in 24 (44%) patients. There was no significant correlation between treatment regimen and treatment failure (p>0.05). In all, nine (16%) of the patients did not respond to medical treatment, and surgical intervention was required. Tularemia should be considered in the differential diagnosis of children presenting with unexplained fever, sore throat, and cervical LAP in endemic areas. Sonographic findings may be useful in the evaluation and staging of this infection.

Antibodies to Both Terminal and Internal B-Cell Epitopes of Francisella tularensisO-Polysaccharide Produced by Patients with Tularemia

Francisella tularensis, the Gram-negative bacterium that causes tularemia, is considered a potential bioterrorism threat due to its low infectivity dose and the high morbidity and mortality from respiratory disease. We previously characterized two mouse monoclonal antibodies (MAbs) specific for the O-polysaccharide (O antigen [OAg]) of F. tularensis lipopolysaccharide (LPS): Ab63, which targets a terminal epitope at the nonreducing end of OAg, and Ab52, which targets a repeating internal OAg epitope. These two MAbs were protective in a mouse model of respiratory tularemia. To determine whether these epitope types are also targeted by humans, we tested the ability of each of 18 blood serum samples from 11 tularemia patients to inhibit the binding of Ab63 or Ab52 to F. tularensis LPS in a competition enzyme-linked immunosorbent assay (ELISA). Although all serum samples had Ab63- and Ab52-inhibitory activities, the ratios of Ab63 to Ab52 inhibitory potencies varied 75-fold. However, the variation was only 2.3-fold for sequential serum samples from the same patient, indicating different distributions of terminal- versus internal-binding antibodies in different individuals. Western blot analysis using class-specific anti-human Ig secondary antibodies showed that both terminal- and internal-binding OAg antibodies were of the IgG, IgM, and IgA isotypes. These results support the use of a mouse model to discover protective B-cell epitopes for tularemia vaccines or prophylactic/therapeutic antibodies, and they present a general strategy for interrogating the antibody responses of patients and vaccinees to microbial carbohydrate epitopes that have been characterized in experimental animals.

In Vitro Antibiotic Susceptibility of &lt;i&gt;Francisella tularensis&lt;/i&gt; Isolates from Japan

The antibiotic susceptibilities of 36 isolates of Japanese Francisella tularensis, an etiological agent of the zoonotic disease tularemia, were analyzed using the E test. All the isolates were susceptible to ciprofloxacin, doxycycline, erythromycin, and gentamicin but resistant to benzylpenicillin and cephalothin. The susceptibility to seven other β-lactams (aztreonam, cefotaxime, cefoxitin, ceftriaxone, cefuroxime, imipenem, and meropenem) varied among the isolates. These findings suggest that the guidelines for the antibiotic treatment of tularemia issued by the World Health Organization are appropriate for Japanese tularemia patients.

Clinical manifestations of 16 oropharyngeal tularemia patients: experience of a referral hospital in the city of Konya, Turkey

In recent years, tularemia's importance has been reemerging in Turkey. However, the majority of tularemia cases were reported in the northern cities of Turkey. In this study, we report 16 oropharyngeal tularemia patients living in rural areas of the city of Konya, which is located in the southern zone of the Central Anatolia Region of Turkey. Materials and methods: Sixteen patients (12 males, 4 females; mean age: 33.7 years, range: 10–73 years) were included in this study. All patients were admitted to our clinic for the evaluation of intractable cervical mass lesions. The diagnosis of tularemia was made after exclusion of other possible causes of the neck masses and the presence of a positive tularemia agglutination test. Each patient was treated with streptomycin and doxycycline for at least 3 weeks. Results: All patients suffered oropharyngeal stiffness. There were neck mass and tonsillitis on the same side in 2 patients, neck mass and acute pharyngitis in 3 patients, and only swelling in the neck region in 11 patients. One of the patients with tonsillitis had common maculopapular skin rashes with fever. Thirteen patients had mass at level 2 zones, 11 patients had mass on the right side of the neck, and 5 patients had mass on the left side of the neck. The right parotid gland was involved in 1 patient. Nine patients were successfully treated with only antimicrobial agents. Lymph node excision was performed in 6 patients, and parotidectomy was performed in 1 patient. Conclusion: This is the second series of tularemia from the city of Konya in Turkey. Tularemia should be considered in the differential diagnosis of patients with intractable neck mass, because early diagnosis and treatment may prevent surgical interventions.