Tularemia

Identification of Francisella tularensis in ascites in the context of typhoidal tularaemia

Tularaemia is a highly infectious, zoonotic disease caused by Francisella tularensis, which has become increasingly prevalent over the past decade. Depending on the route of infection, different clinical manifestations can be observed. We report a case of typhoidal tularaemia presenting as a febrile illness with gastrointestinal symptoms in a patient in her mid-80s. During the acute illness phase and in the context of alcohol-related liver cirrhosis, the patient developed progressive ascites. During paracentesis, spontaneous bacterial peritonitis was consistently reported. Blood culture revealed Gram-negative bacilli identified as F. tularensis upon microscopic examination. Immediate clinical improvement was observed after adaptation to a pathogen-specific antibiotic regime. Typhoidal tularaemia presents general, non-specific symptoms without the local manifestations seen in other forms of the disease, thus representing a diagnostic challenge. In the case of protracted fever and if the epidemiological context as well as possible exposure are compatible, tularaemia should be considered in the differential diagnosis.

Tularemia From Veterinary Occupational Exposure

Tularemia is a disease caused by Francisella tularensis, a highly infectious bacteria that can be transmitted to humans by direct contact with infected animals. Because of the potential for zoonotic transmission of F. tularensis, veterinary occupational risk is a concern. Here, we report on a human case of tularemia in a veterinarian after an accidental needlestick injury during abscess drainage in a sick dog. The veterinarian developed ulceroglandular tularemia requiring hospitalization but fully recovered after abscess drainage and a course of effective antibiotics. To systematically assess veterinary occupational transmission risk of F. tularensis, we conducted a survey of veterinary clinical staff after occupational exposure to animals with confirmed tularemia. We defined a high-risk exposure as direct contact to the infected animal's body fluids or potential aerosol inhalation without use of standard personal protective equipment (PPE). Survey data included information on 20 veterinary occupational exposures to animals with F. tularensis in 4 states. Veterinarians were the clinical staff most often exposed (40%), followed by veterinarian technicians and assistants (30% and 20%, respectively). Exposures to infected cats were most common (80%). Standard PPE was not used during 80% of exposures; a total of 7 exposures were categorized as high risk. Transmission of F. tularensis in the veterinary clinical setting is possible but overall risk is likely low. Veterinary clinical staff should use standard PPE and employ environmental precautions when handling sick animals to minimize risk of tularemia and other zoonotic infections; postexposure prophylaxis should be considered after high-risk exposures to animals with suspected or confirmed F. tularensis infection to prevent tularemia.

Molecular survey on the presence of arthropod-borne bacteria and protozoans in roe deer (Capreolus capreolus) and ticks from Central Italy

Environmental changes, due to climatic emergency and to anthropogenic activities severely impact on the epidemiology of vector borne diseases, mostly when transmitted by ticks. The data about the distribution of microorganisms responsible for them in roe deer (Capreolus capreolus) population living in Italy are scanty and completely lacking in Tuscany, so a molecular survey was carried out to estimate the prevalence of some zoonotic tick-borne pathogens in roe deer, and ticks removed from them, living in areas of Central Italy with high risk of arthropod exposure. Spleen samples from 72 roe deer were tested by PCR for Anaplasma phagocytophilum, Borrelia burgdorferi s.l., Francisella tularensis and piroplasms. Moreover, 345 ticks were removed from 65 roe deer, morphologically or molecularly identified and grouped into 162 pools that were submitted to PCR for detecting the same pathogens. Forty-six (63.88%) roe deer were positive for at least one investigated pathogen: 43 (59.72%) for A. phagocytophilum, 2 (2.78%) for Babesia capreoli, 1 (1.39%) for B. burgdorferi, and 1 (1.39%) for Babesia sp.. No animals were PCR positive for F. tularensis. All ticks were identified as Ixodes ricinus. Seventy-six (46.91%) tick pools showed DNA of one or more pathogens: 66 (40.74%) were positive for A. phagocytophilum, 22 (13.58%) for B. burgodorferi s.l., 6 (3.70%) for B. venatorum and 3 (1.85%) for B. capreoli. No pools were positive for F. tularensis. Two or three pathogens were detected in 23 (14.19%) pools.

Tularemia Proximal Interphalangeal Joint Septic Arthritis: A Case Report

CASE

A case of Francisella tularensis finger proximal interphalangeal joint septic arthritis secondary to feral cat bite is presented. The patient underwent operative debridement on presentation. On postoperative day 5, a gram-negative rod resembling F. tularensis was identified. The patient received 4 weeks of gentamicin for culture-confirmed ulceroglandular tularemia. At the final follow-up, the infection had resolved, and full function of the digit had been regained.

CONCLUSION

Francisella tularensis septic arthritis secondary to a feral cat bite is exceedingly rare but should be considered in the appropriate clinical context. Proper identification and treatment with antibiotics is essential for a positive outcome.

Recently Evolved Francisella-Like Endosymbiont Outcompetes an Ancient and Evolutionarily Associated Coxiella-Like Endosymbiont in the Lone Star Tick (Amblyomma americanum) Linked to the Alpha-Gal Syndrome

Background

Ticks are hematophagous arthropods that transmit various bacterial, viral, and protozoan pathogens of public health significance. The lone star tick (Amblyomma americanum) is an aggressive human-biting tick that transmits bacterial and viral pathogens, and its bites are suspected of eliciting the alpha-gal syndrome, a newly emerged delayed hypersensitivity following consumption of red meat in the United States. While ongoing studies have attempted to investigate the contribution of different tick-inherent factors to the induction of alpha-gal syndrome, an otherwise understudied aspect is the contribution of the tick microbiome and specifically obligate endosymbionts to the establishment of the alpha-gal syndrome in humans.

Materials and Methods

Here we utilized a high-throughput metagenomic sequencing approach to cataloging the entire microbial communities residing within different developmental stages and tissues of unfed and blood-fed ticks from laboratory-maintained ticks and three new geographical locations in the United States. The Quantitative Insights Into Microbial Ecology (QIIME2) pipeline was used to perform data analysis and taxonomic classification. Moreover, using a SparCC (Sparse Correlations for Compositional data) network construction model, we investigated potential interactions between members of the microbial communities from laboratory-maintained and field-collected ticks.

Results

Overall, Francisellaceae was the most dominant bacteria identified in the microbiome of both laboratory-raised and field-collected Am. americanum across all tissues and developmental stages. Likewise, microbial diversity was seen to be significantly higher in field-collected ticks compared with laboratory-maintained ticks as seen with a higher number of both Operational Taxonomic Units and measures of species richness. Several potential positive and negative correlations were identified from our network analysis. We observed a strong positive correlation between Francisellaceae, Rickettsiaceae, and Midichloriaceae in both developmental stages and tissues from laboratory-maintained ticks, whereas ovarian tissues had a strong positive correlation of bacteria in the family Xanthobacteraceae and Rhizobiaceae. A negative interaction was observed between Coxiellaceae and Francisellaceae in Illinois, and all the bacteria detected from ticks from Delaware were negatively correlated.

Conclusion

This study is the first to catalog the microbiome of Am. americanum throughout its developmental stages and different tissue niches and report the potential replacement of Coxiellaceae by Francisellaceae across developmental stages and tissues tested except in ovarian tissues. These unique and significant findings advance our knowledge and open a new avenue of research to further understand the role of tick microbiome in tick-borne diseases and develop a holistic strategy to control alpha-gal syndrome.

Hsp100 Molecular Chaperone ClpB and Its Role in Virulence of Bacterial Pathogens

This review focuses on the molecular chaperone ClpB that belongs to the Hsp100/Clp subfamily of the AAA+ ATPases and its biological function in selected bacterial pathogens, causing a variety of human infectious diseases, including zoonoses. It has been established that ClpB disaggregates and reactivates aggregated cellular proteins. It has been postulated that ClpB’s protein disaggregation activity supports the survival of pathogenic bacteria under host-induced stresses (e.g., high temperature and oxidative stress), which allows them to rapidly adapt to the human host and establish infection. Interestingly, ClpB may also perform other functions in pathogenic bacteria, which are required for their virulence. Since ClpB is not found in human cells, this chaperone emerges as an attractive target for novel antimicrobial therapies in combating bacterial infections.

The Natural History of Aerosolized Francisella tularensis Infection in Cynomolgus Macaques

Tularemia is a severe, zoonotic infection caused by the Gram-negative bacterium Francisella tularensis. Inhalation results in a rapid, severe bacterial pneumonia and sepsis, which can be lethal. Because the cynomolgus macaque is the accepted nonhuman primate model for tularemia, we conducted a natural history study of pneumonic tularemia by exposing macaques to target inhaled doses of 50, 500, or 5000 colony forming units (CFU) of F. tularensis subsp. tularensis SCHU S4. Two animals within the 50 CFU group (calculated doses of 10 and 11 CFU) survived the challenge, while the remainder succumbed to infection. Exposure of cynomolgus macaques to aerosolized SCHU S4 resulted in fever, anorexia, increased white blood cell counts, lymphopenia, thrombocytopenia, increased liver enzymes, alterations in electrocardiogram (ECG), and pathological changes typical of infection with F. tularensis, regardless of the challenge dose. Blood pressure dropped during the febrile phase, particularly as temperature began to drop and macaques succumbed to the disease. ECG analysis indicated that in 33% of the macaques, heart rate was not elevated during the febrile phase (Faget's sign; pulse-temperature disassociation), which has been reported in a similar percentage of human cases. These results indicated that infection of cynomolgus macaques with aerosolized F. tularensis results in similar disease progression and outcome as seen in humans, and that cynomolgus macaques are a reliable animal model to test medical countermeasures against aerosolized F. tularensis.

Neurologic Manifestations of the World Health Organization's List of Pandemic and Epidemic Diseases

The World Health Organization (WHO) monitors the spread of diseases globally and maintains a list of diseases with epidemic or pandemic potential. Currently listed diseases include Chikungunya, cholera, Crimean-Congo hemorrhagic fever, Ebola virus disease, Hendra virus infection, influenza, Lassa fever, Marburg virus disease, Neisseria meningitis, MERS-CoV, monkeypox, Nipah virus infection, novel coronavirus (COVID-19), plague, Rift Valley fever, SARS, smallpox, tularemia, yellow fever, and Zika virus disease. The associated pathogens are increasingly important on the global stage. The majority of these diseases have neurological manifestations. Those with less frequent neurological manifestations may also have important consequences. This is highlighted now in particular through the ongoing COVID-19 pandemic and reinforces that pathogens with the potential to spread rapidly and widely, in spite of concerted global efforts, may affect the nervous system. We searched the scientific literature, dating from 1934 to August 2020, to compile data on the cause, epidemiology, clinical presentation, neuroimaging features, and treatment of each of the diseases of epidemic or pandemic potential as viewed through a neurologist's lens. We included articles with an abstract or full text in English in this topical and scoping review. Diseases with epidemic and pandemic potential can be spread directly from human to human, animal to human, via mosquitoes or other insects, or via environmental contamination. Manifestations include central neurologic conditions (meningitis, encephalitis, intraparenchymal hemorrhage, seizures), peripheral and cranial nerve syndromes (sensory neuropathy, sensorineural hearing loss, ophthalmoplegia), post-infectious syndromes (acute inflammatory polyneuropathy), and congenital syndromes (fetal microcephaly), among others. Some diseases have not been well-characterized from a neurological standpoint, but all have at least scattered case reports of neurological features. Some of the diseases have curative treatments available while in other cases, supportive care remains the only management option. Regardless of the pathogen, prompt, and aggressive measures to control the spread of these agents are the most important factors in lowering the overall morbidity and mortality they can cause.

Tularemia Hand Infection From a Cat Bite—A Case Report

Tularemia is an uncommon infection caused by the bacterium Francisella tularensis. The nonspecific presentation and infrequency with which it is encountered make it a diagnostic challenge. A rare and scarcely reported mode of tularemia inoculation is a cat bite to the hand. We report a cat bite hand infection with tularemia in a 66-year-old woman. She underwent treatment for presumed polymicrobial cellulitis. Over the next 5 days, the symptoms progressed to fever, malaise, and fluctuant lymphadenitis with nodules along draining lymphatics. Cultures grew F tularensis and antibiotics were switched to doxycycline, which resolved the infection. The patient remained symptom-free after the doxycycline was discontinued. The purpose of this case study is to alert treating providers to consider tularemia infection when a hand infection persists, particularly in the context of an animal bite.

Extended-Interval Gentamicin Dosing for Pulmonic Tularemia

Francisella tularensis is a Gram-negative coccobacillus that is rarely encountered in clinical practice. Patients can present with cutaneous, pulmonary, cardiac, mucous membrane, or gastrointestinal involvement. A clinician should have a heightened suspicion in endemic areas or when outbreaks appear. Diagnosis is achieved through serological testing or polymerase chain reaction assays. Although historically the treatment of choice was streptomycin, gentamicin is now preferred due to its availability and relatively safer side effect profile with extended-interval dosing. Limited published evidence exists on the effectiveness of extended-interval gentamicin for tularemia. This case series describes four patients with pulmonic tularemia successfully treated with extended-interval dosing of gentamicin without treatment failure or relapse.

Formation of the Francisella tularensis Biofilm is Affected by Cell Surface Glycosylation, Growth Medium, and a Glucan Exopolysaccharide

Biofilms are matrix-associated communities that enable bacteria to colonise environments unsuitable for free-living bacteria. The facultative intracellular pathogen Francisella tularensis can persist in water, amoebae, and arthropods, as well as within mammalian macrophages. F. tularensis Types A and B form poor biofilms, but F. tularensis mutants lacking lipopolysaccharide O-antigen, O-antigen capsule, and capsule-like complex formed up to 15-fold more biofilm than fully glycosylated cells. The Type B live vaccine strain was also 50% less capable of initiating surface attachment than mutants deficient in O-antigen and capsule-like complex. However, the growth medium of all strains tested also influenced the formation of biofilm, which contained a novel exopolysaccharide consisting of an amylose-like glucan. In addition, the surface polysaccharide composition of the bacterium affected the protein:DNA:polysaccharide composition of the biofilm matrix. In contrast, F. novicida attached to surfaces more efficiently and made a more robust biofilm than Type A or B strains, but loss of O-antigen or capsule-like complex did not significantly affect F. novicida biofilm formation. These results indicated that suppression of surface polysaccharides may promote biofilm formation by F. tularensis Types A and B. Whether biofilm formation enhances survival of F. tularensis in aquatic or other environmental niches has yet to be determined.

A Rare Complication of Oropharyngeal Tularemia: Dacryocystitis

Tularemia is a zoonotic disease caused by Francisella tularensis, a highly virulent gram-negative coccobacillus. Oropharyngeal tularemia, one of the clinical subtypes, is the most common clinical form of the disease in Eastern Europe, including Turkey. This clinical form affects mostly the head and neck region and the most common complaints of patients are mass in the neck, sore throat, and fever. This form of tularemia may be confused with tonsillitis, pharyngitis, or cervical lymphadenitis caused by other microbial agents due to the nonspecific clinical and laboratory features. In this study, we present a patient with nasolacrimal duct obstruction and dacryocystitis caused by oropharyngeal tularemia.

Francisella spp. detected in Dermacentor ticks in Malaysian forest reserve areas

Limited information is available on tropical ticks and tick-borne bacteria affecting the health of humans and animals in the Southeast Asia region. Francisella tularensis is a tick-borne bacterium which causes a potentially life-threatening disease known as tularemia. This study was conducted to determine the occurrence of Francisella spp. in questing ticks collected from Malaysian forest reserve areas. A total of 106 ticks (mainly Dermacentor and Haemaphysalis spp.) were examined for Francisella DNA using a Polymerase chain reaction (PCR) assay targeting the bacterial 16S rDNA. Francisella DNA was detected from 12 Dermacentor ticks. Sequence analysis of the amplified 16S rDNA sequences (1035 bp) show >99% identity with that of Francisella endosymbiont reported in a tick from Thailand. A dendrogram constructed based on the bacterial 16S rDNA shows that the Francisella spp. were distantly related to the pathogenic strains of F. tularensis. Three Francisella-positive ticks were identified as Dermacentor atrosignatus, based on sequence analysis of the tick mitochondrial 16S rRNA gene. Further screening of cattle and sheep ticks (Haemaphysalis bispinosa and Rhipicephalus microplus) and animal samples (cattle, sheep, and goats) did not yield any positive findings. Our findings provide the first molecular data on the occurrence of a Francisella strain with unknown pathogenicity in Dermacentor questing ticks in Malaysia.

Francisella tularensis Transmission by Solid Organ Transplantation, 20171

In July 2017, fever and sepsis developed in 3 recipients of solid organs (1 heart and 2 kidneys) from a common donor in the United States; 1 of the kidney recipients died. Tularemia was suspected only after blood cultures from the surviving kidney recipient grew Francisella species. The organ donor, a middle-aged man from the southwestern United States, had been hospitalized for acute alcohol withdrawal syndrome, pneumonia, and multiorgan failure. F. tularensis subsp. tularensis (clade A2) was cultured from archived spleen tissue from the donor and blood from both kidney recipients. Whole-genome multilocus sequence typing indicated that the isolated strains were indistinguishable. The heart recipient remained seronegative with negative blood cultures but had been receiving antimicrobial drugs for a medical device infection before transplant. Two lagomorph carcasses collected near the donor's residence were positive by PCR for F. tularensis subsp. tularensis (clade A2). This investigation documents F. tularensis transmission by solid organ transplantation.

Francisella tularensis Exposure Among National Park Service Employees During an Epizootic: Devils Tower National Monument, Wyoming, 2015

Introduction: Tularemia is a zoonotic infection caused by the highly infectious bacterium Francisella tularensis. Persons having outdoor professions are more likely than others to be exposed to F. tularensis through increased contact with arthropods, infected animals, and contaminated aerosols. Materials and Methods: After a tularemia epizootic during July and August 2015 at Devils Tower National Monument and an associated tularemia infection in a park employee, we assessed seroprevalence of F. tularensis antibodies, risk factors for F. tularensis seropositivity, and use of protective measures among park employees. Results: Seroprevalence among participating employees was 13% (3/23). Seropositive employees reported multiple risk factors for F. tularensis exposure through both job-related and recreational activities. Activities reported by more seropositive than seronegative employees included using a power blower (67% vs. 5%, p = 0.03), collecting animal carcasses (100% vs. 30%, p = 0.047), and hunting prairie dogs recreationally (67% vs. 5%, p = 0.03). Seropositive employees reported exposure to more ticks (median 30, range 25-35) than seronegative employees (median 6, range 0-25, p = 0.001). Most employees used protective measures (e.g., insect repellent) inconsistently but increased use after receiving educational materials. Conclusions: Educating and enabling at-risk employees to use protective measures consistently, both at work and during recreational activities, can reduce exposure during epizootics.

First Case of Tularemia Reported in Portugal: Probably of Imported Origin

The authors report the case of a 47-year-old man who walked in the countryside on the island of Bornholm, during the summer period. Three days later, fever, myalgias and adynamia began. The serological tests, Real-time PCR and isolation of the bacteria from the culture of lymph biopsy confirmed the presence of Francisella tularensis subsp. holarctica.

The Role and Mechanism of Erythrocyte Invasion by Francisella tularensis

Francisella tularensis is an extremely virulent bacterium that can be transmitted naturally by blood sucking arthropods. During mammalian infection, F. tularensis infects numerous types of host cells, including erythrocytes. As erythrocytes do not undergo phagocytosis or endocytosis, it remains unknown how F. tularensis invades these cells. Furthermore, the consequence of inhabiting the intracellular space of red blood cells (RBCs) has not been determined. Here, we provide evidence indicating that residing within an erythrocyte enhances the ability of F. tularensis to colonize ticks following a blood meal. Erythrocyte residence protected F. tularensis from a low pH environment similar to that of gut cells of a feeding tick. Mechanistic studies revealed that the F. tularensis type VI secretion system (T6SS) was required for erythrocyte invasion as mutation of mglA (a transcriptional regulator of T6SS genes), dotU, or iglC (two genes encoding T6SS machinery) severely diminished bacterial entry into RBCs. Invasion was also inhibited upon treatment of erythrocytes with venom from the Blue-bellied black snake (Pseudechis guttatus), which aggregates spectrin in the cytoskeleton, but not inhibitors of actin polymerization and depolymerization. These data suggest that erythrocyte invasion by F. tularensis is dependent on spectrin utilization which is likely mediated by effectors delivered through the T6SS. Our results begin to elucidate the mechanism of a unique biological process facilitated by F. tularensis to invade erythrocytes, allowing for enhanced colonization of ticks.

Tularemia presenting as suspected necrotic arachnidism

The true danger of the spider bite stems from misdiagnosis and resultant delay in proper treatment of entities that, unlike spider bites, are not self-limited. Obtaining a complete exposure and travel history is central to the development of an accurate and appropriate differential diagnosis.

Variation in Tularemia Clinical Manifestations-Arkansas, 2009-2013

BACKGROUND

Francisella tularensis, although naturally occurring in Arkansas, is also a Tier 1 select agent and potential bioterrorism threat. As such, tularemia is nationally notifiable and mandatorily reported to the Arkansas Department of Health. We examined demographic and clinical characteristics among reported cases and outcomes to improve understanding of the epidemiology of tularemia in Arkansas.

METHODS

Surveillance records on all tularemia cases investigated during 2009-2013 were reviewed.

RESULTS

The analytic dataset was assembled from 284 tularemia reports, yielding 138 probable and confirmed tularemia cases during 2009-2013. Arthropod bite was identified in 77% of cases. Of 7 recognized tularemia manifestations, the typhoidal form was reported in 47% of cases, approximately double the proportion of the more classic manifestation, lymphadenopathy. Overall, 41% of patients were hospitalized; 3% died. The typhoidal form appeared to be more severe, accounting for the majority of sepsis and meningitis cases, hospitalizations, and deaths. Among patients with available antibiotic data, 88% received doxycycline and 12% received gentamicin.

CONCLUSIONS

Contrary to expectation, lymphadenopathy was not the most common manifestation observed in our registry. Instead, our patients were more likely to report only generalized typhoidal symptoms. Using lymphadenopathy as a primary symptom to initiate tularemia testing may be an insensitive diagnostic strategy and result in unrecognized cases. In endemic areas such as Arkansas, suspicion of tularemia should be high, especially during tick season. Outreach to clinicians describing the full range of presenting symptoms may help address misperceptions about tularemia.

MBL, P2X7, and SLC11A1 gene polymorphisms in patients with oropharyngeal tularemia

CONCLUSION

A significant association was found of oropharyngeal tularemia with SLC11A1 allele polymorphism (INT4 G/C) and MBL2 C + 4T (P/Q). These results indicate C allele and Q allele might be a risk factor for the development of oropharyngeal tularemia.

AIM

This study aimed to investigate the relationship of SLC11A1, MBL, and P2X₇ gene polymorphism with oropharyngeal tularemia.

METHODS

The study included totally 120 patients who were diagnosed with oropharyngeal tularemia. Frequencies of polymorphisms in the following genes were analyzed both in the patient and control groups in the study: SLC11A1 (5'(GT)_n Allele 2/3, Int4 G/C, 3' UTR, D543N G/A), MBL (MBL2 C + 4T (P/Q), and P2X₇ (-762 C/T and 1513 A/C).

RESULTS

Among all polymorphisms that were investigated in this study, SLC11A1 gene showed a significance in the distriburtion of polymorphism allelle frequency at the INT4 region. Frequency of C allele was 54 (28%) in patients with oropharyngeal tularemia, and 31 (13%) in the control group (p = 0.006 and OR = 1.96 (1.21-3.20)). An association was detected between MBL2 C + 4T (P/Q) gene polymorphism and oropharyngeal tularemia (p < 0.005 and OR = 0.30 (0.19-0.48)). No significant relation was found between P2X₇ (-762 C/T and 1513 A/C) gene polymorphism and oropharyngeal tularemia in this study (p > 0.05).

Rabbit hunter uveitis: case report of tularemia uveitis

Background

Literature reports on ophthalmological manifestations related to tularemia, a zoonose caused by the bacterium Francisella tularensis, largely refer to Parinaud’s oculoglandular syndrome, which consists of the association of conjunctivitis with preauricular lymphadenitis. In this paper, we report a case of intraocular inflammation during tularemia infection.

Case presentation

A 52-year-old Caucasian man was diagnosed with unilateral uveitis. The uveitis was posterior, with a 2+ vitritis and a large yellowish lesion involving the macula with an overlying sub-retinal detachment, extending inferiorly, and subretinal hemorrhages. Fluorescein angiography showed a late hyperfluorescence with focal vascular leakage. Ultrasound biomicroscopy confirmed the presence of a 3.8 mm parietal granuloma with a few calcifications in the left eye. While extensive work-up eliminated any other infectious and non-infectious etiology, tularemia was diagnosed by advanced serology consisting of two-dimensional Western-immunoblotting. The patient, a hunter, recalled having killed rabbits in the days before the symptoms appeared. Uveitis was rapidly controlled following treatment with doxycycline, yet three years after initiation of the treatment, the patient still complained of loss of vision in the left eye with a central scotoma.

Conclusions

Posterior uveitis may be an infrequent manifestation of tularemia infection, and therefore this infection should be considered in the differential diagnosis of intraocular inflammation in areas where F. tularensis is endemic.

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

INTRODUCTION

We aimed to determine clinical, laboratory and demographical characteristics of tularemia on admission to Emergency Department (ED).

MATERIAL AND METHODS

Medical 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 (-).

RESULTS

Of 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.

CONCLUSION

Tularemia is a disease of elderly people living in rural areas. Contact with rodents also increases risk of tularemia in suspected patients.

Detection of Lyme Disease and Q Fever Agents in Wild Rodents in Central Italy

The maintenance of tick-borne disease agents in the environment strictly depends on the relationship between tick vectors and their hosts, which act as reservoirs for these pathogens. A pilot study aimed to investigate wild rodents as reservoirs for zoonotic tick-borne pathogens (Borrelia burgdorferi sensu lato (s.l.), Coxiella burnetii, Francisella tularensis, and Anaplasma phagocytophilum) was carried out in an area of Gran Sasso e Monti della Laga National Park (Abruzzi Region, central Italy), a wide protected area where, despite sporadic reports of infection in humans and animals, eco-epidemiological data on these diseases are still not available. Rodents were trapped and released at the capture site after the collection of feeding ticks and blood samples. In all, 172 ticks were collected; the most frequent species was Ixodes acuminatus (53%). Out of 88 tick pools, 11 resulted positive for C. burnetii and 13 for B. burgdorferi s.l.; the Borrelia afzelii genospecies was identified in one Ixodes ricinus tick collected from one Apodemus sp. rodent. Out of 143 blood samples, seven Apodemus spp. and five Myodes glareolus were positive for B. burgdorferi s.l. and two Apodemus spp. were positive for C. burnetii. All samples (ticks and blood) were negative for F. tularensis and A. phagocytophilum. This is the first report of B. burgdorferi s.l. in the environment for Abruzzi Region. Data on the presence of B. burgdorferi s.l. are similar to that observed in other Mediterranean countries. The present work is also the first report of C. burnetii in wild rodents in Italy. C. burnetii infection has been largely investigated in Italy in ruminant farms by serology and molecular methods, but information on ecology and on the wild cycle are still lacking. Further studies including genotyping should be performed and species-specific differences between wild rodent reservoirs of Q fever and Lyme disease agents should be investigated.

PATHOGENESIS AND IMMUNE RESPONSES OF FRANCISELLA TULARENSIS STRAINS IN WILD-CAUGHT COTTONTAIL RABBITS (SYLVILAGUS SPP.)

Francisella tularensis is a highly virulent, zoonotic bacterium that causes significant natural disease and is of concern as an organism for bioterrorism. Serologic testing of wildlife is frequently used to monitor spatial patterns of infection and to quantify exposure. Cottontail rabbits (Sylvilagus spp.) are a natural reservoir for F. tularensis in the US, although very little work has been done experimentally to determine how these animals respond to infection; thus, information gathered from field samples can be difficult to interpret. We characterized clinical disease, bacteremia, pathology, and antibody kinetics of North American cottontail rabbits experimentally infected with five strains of F. tularensis. Rabbits were infected with four field strains, including MA00-2987 (type A1b), WY96-3418 (type A2), KY99-3387, and OR96-0246 (type B), and with SchuS4 (type A1a), a widely used, virulent laboratory strain. Infection with the different strains of the bacterium resulted in varied patterns of clinical disease, gross pathology, and histopathology. Each of the type A strains were highly virulent, with rabbits succumbing to infection 3-13 d after infection. At necropsy, numerous microabscesses were observed in the livers and spleens of most rabbits, associated with high bacterial organ burdens. In contrast, most rabbits infected with type B strains developed mild fever and became lethargic, but the disease was infrequently lethal. Those rabbits infected with type B strains that survived past 14 d developed a robust humoral immune response, and F. tularensis was not isolated from liver, spleen, or lung of those animals. Understanding F. tularensis infection in a natural reservoir species can guide serosurveillance and generate new insights into environmental maintenance of this pathogen.

Tularemia, a re-emerging infectious disease in Iran and neighboring countrie

OBJECTIVES

Tularemia is a zoonotic disease transmitted by direct contact with infected animals and through arthropod bites, inhalation of contaminated aerosols, ingestion of contaminated meat or water, and skin contact with any infected material. It is widespread throughout the northern hemisphere, including Iran and its neighbors to the north, northeast, and northwest.

METHODS

In this paper, the epidemiology of tularemia as a re-emerging infectious disease in the world with a focus on Iran and the neighboring countries is reviewed.

RESULTS

In Iran, positive serological tests were first reported in 1973, in wildlife and domestic livestock in the northwestern and southeastern parts of the country. The first human case was reported in 1980 in the southwest of Iran, and recent studies conducted among at-risk populations in the western, southeastern, and southwestern parts of Iran revealed seroprevalences of 14.4, 6.52, and 6%, respectively.

CONCLUSIONS

Several factors may explain the absence of reported tularemia cases in Iran since 1980. Tularemia may be underdiagnosed in Iran because Francisella tularensis subspecies holarctica is likely to be the major etiological agent and usually causes mild to moderately severe disease. Furthermore, tularemia is not a disease extensively studied in the medical educational system in Iran, and empirical therapy may be effective in many cases. Finally, it should be noted that laboratories capable of diagnosing tularemia have only been established in the last few years. Since both recent and older studies have consistently found tularemia antibodies in humans and animals, the surveillance of this disease should receive more attention. In particular, it would be worthwhile for clinical researchers to confirm tularemia cases more often by isolating F. tularensis from infected humans and animals.

Structure and function of REP34 implicates carboxypeptidase activity in Francisella tularensis host cell invasion

Francisella tularensis is the etiological agent of tularemia, or rabbit fever. Although F. tularensis is a recognized biothreat agent with broad and expanding geographical range, its mechanism of infection and environmental persistence remain poorly understood. Previously, we identified seven F. tularensis proteins that induce a rapid encystment phenotype (REP) in the free-living amoeba, Acanthamoeba castellanii. Encystment is essential to the pathogen's long term intracellular survival in the amoeba. Here, we characterize the cellular and molecular function of REP34, a REP protein with a mass of 34 kDa. A REP34 knock-out strain of F. tularensis has a reduced ability to both induce encystment in A. castellanii and invade human macrophages. We determined the crystal structure of REP34 to 2.05-Å resolution and demonstrate robust carboxypeptidase B-like activity for the enzyme. REP34 is a zinc-containing monomeric protein with close structural homology to the metallocarboxypeptidase family of peptidases. REP34 possesses a novel topology and substrate binding pocket that deviates from the canonical funnelin structure of carboxypeptidases, putatively resulting in a catalytic role for a conserved tyrosine and distinct S1' recognition site. Taken together, these results identify REP34 as an active carboxypeptidase, implicate the enzyme as a potential key F. tularensis effector protein, and may help elucidate a mechanistic understanding of F. tularensis infection of phagocytic cells.

An atypical case of tularemia presented with pseudoptosis

We report an unusual case of tularemia involving pseudoptosis associated with deterioration of the lymphatic drainage system extending from the upper eyelid to the preauricular lymph nodes. A 16-week pregnant patient was admitted with an absess on the neck, preauricular lymphadenopathy, and pseudoptosis on the left side. The micro-agglutination test was positive for Francisella tularensis antibody at a titer of 1/200. The absess was surgically drained and oral cefuroxime was given for 6 weeks. Two weeks after drainage, the pseudoptosis improved due to the recovery of lymphatic drainage system of the eyelid and remission of the absess on the neck. Our case report contributes to the medical literature on tularemia during pregnancy and informs healthcare professionals on the management of the infection in such cases.

The use of resazurin as a novel antimicrobial agent against Francisella tularensis

The highly infectious and deadly pathogen, Francisella tularensis, is classified by the CDC as a Category A bioterrorism agent. Inhalation of a single bacterium results in an acute pneumonia with a 30-60% mortality rate without treatment. Due to the prevalence of antibiotic resistance, there is a strong need for new types of antibacterial drugs. Resazurin is commonly used to measure bacterial and eukaryotic cell viability through its reduction to the fluorescent product resorufin. When tested on various bacterial taxa at the recommended concentration of 44 μM, a potent bactericidal effect was observed against various Francisella and Neisseria species, including the human pathogens type A F. tularensis (Schu S4) and N. gonorrhoeae. As low as 4.4 μM resazurin was sufficient for a 10-fold reduction in F. tularensis growth. In broth culture, resazurin was reduced to resorufin by F. tularensis. Resorufin also suppressed the growth of F. tularensis suggesting that this compound is the biologically active form responsible for decreasing the viability of F. tularensis LVS bacteria. Replication of F. tularensis in primary human macrophages and non-phagocytic cells was abolished following treatment with 44 μM resazurin indicating this compound could be an effective therapy for tularemia in vivo.

Francisella tularensis intracellular survival: to eat or to die

Francisella tularensis is a highly infectious facultative intracellular bacterium causing the zoonotic disease tularemia. Numerous attributes required for F. tularensis intracellular multiplication have been identified recently. However, the mechanisms by which the majority of them interfere with the infected host are still poorly understood. The following review summarizes our current knowledge on the different steps of Francisella intramacrophagic life cycle and expands on the importance of nutrient acquisition.

Non-lyme tick-borne diseases: a neurological perspective

Tick-borne diseases are prevalent throughout the world and present a diagnostic challenge owing to their nonspecific clinical symptoms. Many tick-borne diseases involve the central and peripheral nervous systems. Early diagnosis or at least suspicion of a tick-borne cause is necessary to institute early empiric treatment. After a brief review of tick biology, we present the most common tick-borne diseases. A brief discussion of epidemiology, the transmission route, and pathogenesis is followed by a discussion of the clinical manifestations, diagnosis and treatment options when available. The review emphasizes the infectious causes with a significant neurological manifestation.

Unilateral acute dacryocystitis associated with oculoglandular tularemia: a case report

PURPOSE

To describe an unusual case of oculoglandular tularemia associated with unilateral acute dacryocystitis and purulent conjunctivitis with 18 weeks pregnancy.

METHODS

It is difficult to culture francisella tularensis on media so serological tests such as micro-agglutination methods are used to diagnose the infection. PCR test results were weak positive. The serum sample was analyzed for the presence of f. tularensis antibody, which was determined positive with a titer of 1/160.

RESULTS

Oral amoksicilin-clavulonic acid treatment was applied to the patient because of the side-effects of other antibiotics on the fetus. Dacryocystitis was surgically drained but relapsed a few weeks later, so it was drained again and a ciprofloksasin-impregnated sponge was placed into the tissue defect that occured after drainage. No relapses were seen after recovery of dacryocystitis.

CONCLUSIONS

Oculoglandular tularemia is not only suspected in cases who complain of fever, cervical lymphadenopathy and purulent conjunctivitis, it should also be suspected in cases who are admitted to the hospital with acute dacryocystitis, which is a rare component of oculoglandular syndrome.

Treatment of tularemia in pregnant woman, France

A pregnant woman who had oropharyngeal tularemia underwent treatment with azithromycin and lymph node resection and recovered without obstetrical complication or infection in the child. Azithromycin represents a first-line treatment option for tularemia during pregnancy in regions where the infecting strains of Francisella tularensis have no natural resistance to macrolides.

Organs of BALB/c mice can be injured in course of tularemia

BACKGROUND

Francisella tularensis is a biological agent exploitable for bioterrorism and biological warfare purposes due to serious pathogenic progression and easy dissemination. Despite intensive research in the past, some adverse consequences remain unclear. One consequence of this pathogen is oxidative stress.

AIMS

The aim of this study was to undertake ex vivo assays for monitoring the disease in mice and increase our knowledge of the oxidative stress induced by tularemia.

METHODS

The mouse BALB/c model was chosen and the animals were infected by a dose 10(4) CFU of F. tularensis. After five days, the animals were euthanized. Blood immediately processed in plasma, spleen and liver were sampled from the cadavers. Oxidative stress markers, cytokines and histopathological were undertaken.

RESULTS

There was a significant link between oxidative stress and tularemia. Particularly elevated levels of malondialdehyde and decreased levels of low molecular weight antioxidants were found in the liver and spleen of tularemia-infected animals. The histopathological findings correlated well with the oxidative stress markers. The liver and spleen were proven to be significantly at risk from the disease and an association between stress and neutrophils in the affected organs was found. The histopathology excluded risk to other organs such as the kidney and or heart.

CONCLUSIONS

Oxidative stress plays a significant role in tularemia infection in mice and this was confirmed by the histology.

A Randomized Trial of Facilitated Family-Centered Rounds

BACKGROUND:

Family-centered rounds (FCR) are becoming the status quo for inpatient pediatric medical care; however, barriers still exist. The use of facilitators in FCR is gaining popularity. Although facilitators can increase comfort with FCR, the choice of preferred facilitator has not been studied by using rigorous methodology. In this study, we performed a randomized trial of facilitated FCR with bunnies and clowns, 2 commonly mentioned facilitators, and compared their results with the usual care condition.

METHODS:

The 3 floor teams were randomized to have rounds facilitated with bunnies and clowns or the usual care model facilitated by distracted residents and overbearing attending physicians. Infection control procedures were instituted. Outcome measures were parent satisfaction scores, use of anxiolytic agents during examinations as part of FCR, resident satisfaction, and the number of times presenters were interrupted by their attending. Differences between the experimental and control groups were analyzed by using t tests, χ2 statistics, and multiple regression analysis. Qualitative analyses were also performed by using participant-observers.

RESULTS:

Bunnies had the best overall improvement in parent satisfaction, anxiety, and resident satisfaction. Both intervention groups were successful at reducing attending interruptions. The clown arm was suspended by the Data Safety Monitoring Board before study completion due to adverse events.

DISCUSSION:

Facilitated FCR has the potential to improve satisfaction among parents, patients, and residents, and to decrease attending interruptions. Care needs to be taken, however, to avoid unanticipated adverse effects from potentially emotionally damaging interventions. Tularemia was not identified in any of our treatment conditions.

Unusual presentatıon of oropharyngeal tularemıa: a case report

Tularemia is a bacterial zoonotic disease that is caused by Francisella tularensis and among the infectious reasons that cause fever of unknown origin (FUO) in children. Typhoidal or pneumonic tularemia can manifest predominantly as FUO. However, presentation of oropharyngeal tularemia as FUO is uncommon. Here, we report a case of an 11-month-old infant with oropharyngeal tularemia presenting as FUO. To the best of our knowledge, this clinical presentation of oropharyngeal tularemia has not been previously reported in literature.

Medical aspects of bio-terrorism

INTRODUCTION

Bioterrorism is a terrorist action involving the intentional release or dissemination of a biological warfare agent (BWA), which includes some bacteria, viruses, rickettsiae, fungi or biological toxins. BWA is a naturally occurring or human-modified form that may kill or incapacitate humans, animals or plants as an act of war or terrorism. BWA is a weapon of choice for mass destruction and terrorism, because of the incubation period, less effective amount than chemical warfare agents, easily distribution, odorless, colorless, difficult to detect, no need of specialized equipment for production and naturally distribution which can easily be obtained. BWA may be disseminating as an aerosol, spray, explosive device, and by food or water.

CLASSIFICATION

Based on the risk for human health, BWAs have been prioritized into three categories of A, B and C. Category A includes microorganisms or toxins that easily spread, leading to intoxication with high death rates such as Anthrax, Botulism, Plague, Smallpox, Tularemia and Viral hemorrhagic fevers. Category B has lower toxicity with wider range, including Staphylococcal Entrotoxin type B (SEB), Epsilon toxin of Clostridium perfringens, Ricin, Saxotoxins, Abrin and Trichothecene mycotoxins. The C category includes emerging pathogens that could also be engineered for mass spread such as Hanta viruses, multidrug-resistant tuberculosis, Nipah virus, the tick-borne encephalitis viruses, hemorrhagic fever viruses and yellow fever. CLINICAL MANIFESTATIONS OF BIOTOXINS IN HUMAN: Clinical features and severity of intoxication depend on the agent and exposed dose, route of entry, individual variation and environmental factors. Onset of symptoms varies from 2-24 h in Ricin to 24-96 h in Botulism. Clinical manifestations also vary from irritation of the eyes, skin and mucus membranes in T2 toxin to an acute flaccid paralysis of bilateral cranial nerve impairment of descending manner in botulism. Most of the pyrogenic toxins such as SEB produce the same signs and symptoms as toxic shock syndrome including a rapid drop in blood pressure, elevated temperature, and multiple organ failure.

MANAGEMENT

There is no specific antidote or effective treatment for most of the biotoxins. The clinical management is thus more supportive and symptomatic. Fortunately vaccines are now available for most of BWA. Therefore, immunization of personnel at risk of exposure is recommended.

CONCLUSION

Biotoxins are very wide and bioterrorism is a heath and security threat that may induce national and international problems. Therefore, the security authorities, health professional and even public should be aware of bioterrorism.

Francisella tularensis Bacteremia: A Case Report from Sudan

Francisella tularensis is a highly virulent intracellular gram-negative bacterium. The organism is usually isolated from wild and domestic animals and invertebrate. Man gets infection by direct contact with those animals or their products but the most common mode of transmission is via arthropod vectors. The disease is endemic in North America, parts of Europe, and Asia but has never been reported in Africa. A 29-year old male living in a rural area of Southern Sudan has been maintained on continuous ambulatory peritoneal dialysis for two years. He presented to our center in May 2010 complaining of fever, dry cough, shortness of breath, and abdominal discomfort for four days. He was very ill, pale, and dehydrated. There were enlarged tender submandibular lymph nodes, but no mouth ulcers or other palpable lymph nodes. Peritonitis was excluded by effluent white blood cell count and culture. Empiric antibiotic treatment with ceftriaxon, and ciprofloxacin was started. Gram-negative coccobacilli were isolated by blood culture. The organism was identified as Francisella tularensis. We started him on a ten-day course of gentamicin after which he improved. This is, to the best of our knowledge, the first reported case of bacteremia caused by Francisella tularensis in Sudan.

Tularemia progression accompanied with oxidative stress and antioxidant alteration in spleen and liver of BALB/c mice

Francisella tularensis is the causative agent of tularemia. It is an intracellular pathogen with the ability to survive within phagosomes and induce pyroptotic cell death. In this study, we attempted to prove whether oxidative imbalance plays a significant role in tularemia pathogenesis. In our experimental model, we subcutaneously infected female BALB/c mice (dose 10(5) CFU of F. tularensis LVS). Liver, spleen, and blood were collected from mice at regular intervals from days 1-15 after infection. The bacterial burden was assessed by a cultivation test. The burden was unchanging from the 2(nd) to 6(th) day after infection. The bacterial burden corresponded to the plasmatic level of IFN-γ, IL-6, and liver malondialdehyde. After the phase of acute bacteraemia and the innate immunity reaction, the levels of reduced glutathione and total low molecular weight antioxidants decreased significantly and the activity of caspase-3 increased in the liver. The level of reduced glutathione decreased to 25% of the original level, and the total level of low molecular weight antioxidants was less than 50% of the initial amount. The demonstrated effects of tularemia-induced pathology had a more extensive impact on the liver than on the spleen.