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# Tularaemia

Tularaemia is a bacterial infection caught from rabbits, rodents, ticks or flies that causes fever, a [skin](https://durgical.com/en/anatomy/skin/) sore and swollen lymph nodes.

Updated 2026-11-01

## Structures involved

Tap one to see what it is and open it in 3D.

- [Skin](https://durgical.com/en/anatomy/skin/)
- [Cubital nodes](https://durgical.com/en/anatomy/cubital-nodes/)
- [Lateral axillary nodes](https://durgical.com/en/anatomy/lateral-axillary-nodes/)
- [Neck lymph nodes](https://durgical.com/en/anatomy/lymph-nodes-of-neck/)
- [Palatine tonsils](https://durgical.com/en/anatomy/palatine-tonsil/)
- [Superficial inguinal nodes](https://durgical.com/en/anatomy/superficial-inguinal-nodes/)

## Microorganisms that cause it

- [Francisella tularensis](https://durgical.com/en/microbiology/francisella-tularensis/)

## Why it happens

- [Granulomatous inflammation: caseating vs non-caseating, the causes to know](https://durgical.com/en/general-pathology/granulomatous-inflammation-caseating-vs-non-caseating-the-causes-to-know/)
- [Patterns of necrosis: coagulative, liquefactive, caseous, fat, fibrinoid, gangrenous](https://durgical.com/en/general-pathology/patterns-of-necrosis-coagulative-liquefactive-caseous-fat-fibrinoid-gangrenous/)
- [Lymph node and spleen under the microscope](https://durgical.com/en/histology/lymph-node-and-spleen-under-the-microscope/)

## What it is

A zoonotic infection by Francisella tularensis. Its clinical form depends on how the bacteria enter: through the skin, eye, mouth or lungs. The most common form is a skin ulcer at the entry site with enlarged regional lymph nodes.

## Who gets it

Tularaemia occurs mainly in the Northern Hemisphere: the United States, Canada, Europe and Asia, with a few reports from Central America. It is not known to be endemic in Colombia or the rest of South America, so local cases would point to travel or a laboratory or deliberate release. It is a classic exam topic because the organism is one of the recognised bioterrorism agents.

## Causes

- Francisella tularensis, a small, aerobic Gram-negative coccobacillus that survives inside macrophages
- Reservoirs: rabbits, hares and rodents; vectors: ticks and deer flies
- Entry through a bite, skinning or handling infected animals, contaminated water or food, or inhaled dust and aerosols
- Very low infectious dose; no spread from person to person

## Risk factors

- Hunting, skinning or butchering rabbits and hares
- Tick or deer fly bites in endemic areas
- Farming, landscaping or mowing over animal carcasses (aerosols)
- Laboratory work with cultures of the organism
- Travel to endemic regions of North America, Europe or Asia

## Pathophysiology

After entry the bacteria multiply locally and are carried to regional lymph nodes, where they live inside macrophages and avoid killing. Local necrosis forms an ulcer and enlarged, sometimes suppurating nodes. Spread through blood seeds the lungs, [liver](https://durgical.com/en/anatomy/liver/) and [spleen](https://durgical.com/en/anatomy/spleen/), producing granulomas with central necrosis. Inhaled organisms cause pneumonia with hilar node enlargement.

## Classification

- Ulceroglandular (most common): skin ulcer plus regional lymphadenopathy
- Glandular: lymphadenopathy without an ulcer
- Oculoglandular: conjunctivitis with preauricular nodes
- Oropharyngeal: pharyngitis, mouth ulcers and neck nodes after contaminated food or water
- Pneumonic: the most severe form, from inhalation or blood spread
- Typhoidal: fever and systemic illness without a local focus

## Symptoms and signs

- Abrupt high fever, chills, headache, muscle aches and malaise a few days after exposure
- Painful papule at the entry site that becomes a punched-out ulcer, often on a finger or hand
- Large, tender lymph nodes draining the site (axilla, elbow, groin or neck), which may suppurate
- Red, painful eye with swollen nodes in front of the ear in the oculoglandular form
- Dry cough, chest pain and shortness of breath in the pneumonic form

## Red flags

- Pneumonia, especially in several people at the same time (consider a deliberate release)
- Hypotension or confusion suggesting the typhoidal or septic form
- Fluctuant nodes that do not respond to antibiotics
- Treatment delayed more than two weeks

## Diagnosis

**Clinical**
Suspected from fever with an ulcer and regional lymphadenopathy after contact with rabbits, rodents, ticks or flies, or from atypical pneumonia with a compatible exposure. Treatment starts on suspicion.

**Tests**
Serology showing a fourfold rise in antibodies between acute and convalescent samples; PCR of ulcer swab, node aspirate or respiratory samples; culture on cysteine-enriched media. The laboratory must be warned in advance because the organism easily infects laboratory staff.

**Imaging**
[Chest](https://durgical.com/en/anatomy/region/chest/) radiograph in the pneumonic form: patchy infiltrates, hilar lymph node enlargement and pleural effusion.

## Differential diagnosis

- Cat-scratch disease (bartonellosis)
- Plague (more fulminant, bubo without an ulcer)
- Staphylococcal or streptococcal lymphadenitis
- Cutaneous anthrax (painless black eschar)
- Lymphocutaneous sporotrichosis or mycobacterial infection

## Goal of treatment

Start effective antibiotics early, prevent spread to the lungs and blood, drain suppurative nodes when needed and avoid laboratory exposures.

## Treatment

**Medical**
An aminoglycoside (gentamicin or streptomycin) for severe disease; a fluoroquinolone (ciprofloxacin or levofloxacin) for mild to moderate disease; a tetracycline (doxycycline) is an alternative but not alone for severe or delayed cases.

**Medical**
Antibiotic prophylaxis with doxycycline or a fluoroquinolone after a laboratory or mass exposure.

**Procedure**
Drainage of suppurating lymph nodes that do not settle with antibiotics.

**Follow-up**
[Kidney](https://durgical.com/en/anatomy/kidney/) function and drug levels during aminoglycoside therapy; standard precautions only, because there is no person-to-person spread.

## Complications

- Suppuration of lymph nodes with chronic drainage
- Pneumonia, lung abscess and pleural effusion
- Sepsis, rhabdomyolysis and kidney failure
- Meningitis, pericarditis or osteomyelitis (rare)

## Prognosis

With prompt treatment mortality is low. Untreated pneumonic and typhoidal disease can be fatal, and node enlargement and fatigue may persist for weeks after cure.

## Prevention

- Gloves and care when handling or skinning wild animals
- Tick and fly protection with clothing and repellents
- Avoid mowing over dead animals and drinking untreated water in endemic areas
- Biosafety precautions in laboratories

## Test yourself

Think of the answer, then tap the question to see it.

## Which animal exposure is classic for tularaemia?

Hunting or skinning rabbits or hares ("rabbit fever"), along with tick and deer fly bites.

## What is the most common clinical form?

Ulceroglandular: a skin ulcer at the entry site with tender regional lymph nodes.

## Why must the laboratory be told when tularaemia is suspected?

Francisella tularensis is highly infectious in culture and causes laboratory-acquired infections.

## Which antibiotic class is preferred for severe tularaemia?

Aminoglycosides (gentamicin or streptomycin).

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## Related conditions

- [Plague](https://durgical.com/en/conditions/plague/)
- [Bartonella infections (cat-scratch disease, Carrion disease)](https://durgical.com/en/conditions/bartonella-infections/)
- [Anthrax](https://durgical.com/en/conditions/anthrax/)
- [Brucellosis](https://durgical.com/en/conditions/brucellosis/)
- [Rickettsial infections (spotted fever)](https://durgical.com/en/conditions/rickettsial-infections/)
- [Community-acquired pneumonia](https://durgical.com/en/conditions/community-acquired-pneumonia/)
- [Sepsis and septic shock](https://durgical.com/en/conditions/sepsis-and-septic-shock/)
- [Tuberculosis](https://durgical.com/en/conditions/tuberculosis/)

Educational information, not medical advice. For any symptom, see a health professional.

Sources: [Signs and Symptoms of Tularemia | Tularemia | CDC](https://www.cdc.gov/tularemia/signs-symptoms/index.html) (Centers for Disease Control and Prevention, 2024); [Clinical Care of Tularemia | Tularemia | CDC](https://www.cdc.gov/tularemia/hcp/clinical-care/index.html) (Centers for Disease Control and Prevention, 2024); [About Tularemia | Tularemia | CDC](https://www.cdc.gov/tularemia/about/index.html) (Centers for Disease Control and Prevention, 2024).

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Source: https://durgical.com/en/conditions/tularaemia/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/conditions/tularaemia/