Tularemia

What is tularemia?

Tularemia is an illness you get from the bacterium Francisella tularensis (F. tularensis). It causes your lymph nodes to painfully swell and other symptoms in your lungs, eyes, throat and intestines, depending on where the bacteria infects you.

Tularemia is a zoonotic disease, which means it spreads between animals and humans. Commonly called “rabbit fever” or “deer fly fever,” people get tularemia from exposure to deer flies and ticks that have F. tularensis infections. You can also get it from contact with infected animals (generally rabbits, hares and rodents) or food and water sources contaminated with the bacteria.

What does tularemia look like?

Tularemia can cause your lymph nodes to swell severely, which looks like large bumps on your body. Sometimes it causes broken skin (ulceration) at the site where F. tularensis bacteria entered your body.

Who does tularemia affect?

Tularemia can affect anyone, but your work, hobbies or other aspects of your life can put you in closer contact with animals and bugs infected with F. tularensis. You could be at higher risk for tularemia if you:

• Hunt game or handle uncooked meat.
• Are a veterinarian, animal control officer or anyone else who handles animals as part of their job.
• Are around biting insects.
• Have a weakened immune system (due to HIV, cancer or immunosuppressant medications).
• Are a farm worker, sheep shearer or work with F. tularensis in a lab. These jobs put you at risk for pneumonic tularemia.
• Live in the central part of the U.S. Most cases of tularemia are reported in Arkansas, Oklahoma, Missouri, Nebraska, South Dakota and Kansas.

How common is tularemia?

There are fewer than 300 cases per year reported in the U.S., coming from all states except Hawaii, but it’s most common in the south-central United States, the Great Plains region, and parts of Massachusetts.

What part of your body does tularemia affect?

Tularemia can affect your lymph nodes, skin, eyes, throat, intestines (gut) or lungs. In severe cases, it can cause inflammation in any organ, including your brain and heart.

How does tularemia affect my body?

F. tularensis bacteria get into your body and are “eaten” (engulfed) by cells of your immune system. Typically these cells would destroy the bacteria, but instead, the bacteria multiply inside of them. The bacteria destroy the immune cell and flood out into your body to infect other cells.

The destruction of cells and your immune system’s response to the bacteria causes symptoms in the part of your body that’s infected.

What are the types of tularemia?

Tularemia has several forms, depending on how you got infected with F. tularensis and where your symptoms are. Types of tularemia include:

Ulceroglandular tularemia

Ulceroglandular tularemia is the most common form of tularemia. You usually get it from being bitten by a tick or an infected animal. It affects your skin and lymph nodes.

Glandular tularemia

Glandular tularemia is similar to ulceroglandular tularemia, but it only affects your lymph nodes. You get glandular tularemia from a tick bite or directly from an infected animal.

Oculoglandular tularemia

You get oculoglandular tularemia if you get contaminated water or body fluids in your eye. It causes symptoms in and around your infected eye. Oculoglandular tularemia usually doesn’t affect both eyes.

Oropharyngeal tularemia

You get oropharyngeal tularemia from eating contaminated food, drinking contaminated water or touching your hands to your mouth without washing them. It causes a sore throat and sometimes digestive (gastrointestinal) symptoms.

Pneumonic tularemia

Pneumonic tularemia is the most serious form of tularemia. It causes symptoms similar to pneumonia. You can get pneumonic tularemia two ways:

• Breathing in F. tularensis.
• F. tularensis spreading to your lungs from somewhere else in your body.

Typhoidal tularemia

Typhoidal tularemia causes a high fever and affects many parts of your body. You can get typhoidal tularemia the same way as other forms of tularemia.

Is tularemia like Lyme disease?

While tularemia has some symptoms that are similar to Lyme disease, they affect your body differently. Tularemia can affect many parts of your body and cause life-threatening illness. Lyme is usually not life-threatening, though it can cause long-lasting symptoms that are hard to treat.

What are signs and symptoms of tularemia?

Symptoms of tularemia depend on what form you have. Most forms cause a fever, various types of rash and additional symptoms specific to where the infection is in your body.

Symptoms of ulceroglandular and glandular tularemia

• Fever.
• Very large, swollen and painful lymph nodes.
• Open wound (ulcer or lesion) on your skin (ulceroglandular tularemia only).

Symptoms of oculoglandular tularemia

• Eye pain.
• Watery eyes (tearing).
• Sensitivity to light (photophobia).
• Swollen, painful lymph nodes around your ears or neck.
• Open sore on your eye (corneal ulceration).

Symptoms of oropharyngeal tularemia

• Fever.
• Severe sore throat.
• Swollen, red throat with white patches.

Some people may also have:

• Vomiting.
• Diarrhea (can be bloody).
• Abdominal (stomach) pain.

Symptoms of pneumonic tularemia

• Fever.
• Cough.
• Shortness of breath (dyspnea).
• Chest pain or tightness.
• Muscles aches.
• Red bumps or rash (erythema nodosum).
• Coughing up blood (hemoptysis).

Symptoms of typhoidal tularemia

• High fever.
• Chills.
• Headache.
• Loss of appetite.
• Muscle aches.
• Sore throat.
• Abdominal (stomach) pain.
• Diarrhea.
• Nausea or vomiting.
• Confusion.

How long after I’ve been exposed to tularemia will I get sick?

The incubation period for tularemia, or time between exposure and the start of symptoms, is three to five days. Some people can go without symptoms for up to two weeks.

What causes tularemia?

The bacterium F. tularensis causes tularemia. It lives in animals (when animals carry diseases like this, they’re known as “reservoirs”) — usually rabbits, hares, rodents and cats — and can ticks and other biting insects can also carry it.

There are two types of F. tularensis, type A and type B. Type A causes more serious illness and is found in the U.S. Type B causes mild symptoms and is found in North America and most other parts of the world.

How does tularemia spread?

Tularemia spreads (is transmitted) in many different ways. You can get tularemia from:

• Bites from ticks, mosquitos, deer flies and other biting insects.
• Bites from infected animals.
• Touching infected animals. If you touch the infected tissue or body fluids of an animal, it can get into your body through breaks in your skin. You can also get it in your eyes, nose or mouth if you touch your face after contact with F. tularensis.
• Drinking contaminated water or eating contaminated food.
• Breathing in an aerosol (mist) that has F. tularensis in it. This can happen if a lawn mower or piece of farming equipment runs over an infected animal.

Is tularemia contagious?

No, tularemia isn’t contagious — there’s no evidence that it can spread directly from person to person. However, it’s highly infectious, which means exposure to even small amounts of the bacteria can be enough for you to get sick .

Can you eat an animal with tularemia?

While cooking to a safe temperature kills bacteria, you shouldn’t eat an animal that you know had tularemia.

How is tularemia diagnosed?

To diagnose tularemia, a healthcare provider will examine you, ask you about your symptoms and test your blood or other body fluids. Depending on your symptoms, they might look at your lymph nodes, your throat, your eyes and any ulcers, bumps or rashes you have on your skin.

What tests will be done to diagnose tularemia?

Tests and imaging your provider might do to diagnose tularemia include:

• Blood tests. A sample of blood taken from your arm will be sent to a lab. The lab will look for signs of tularemia and might see if F. tularensis grows from it. At first, your blood test may look normal because F. tularensis can be slow-growing. You may have to repeat blood tests a few weeks later.
• Biopsy. If you have large lymph nodes or ulcers, your provider may take a sample of your tissue for biopsy. A lab will test the sample for F. tularensis or see if it grows from the sample.
• Nasal or throat swab. Your provider may use a long stick with a soft tip (swab) to get a sample of mucus from your nose or throat. A lab will test the sample for F. tularensis or see if it grows from the sample.
• Pleural fluid test (thoracentesis). If you have fluid around your lungs, a provider may take a sample of it during a thoracentesis. A lab will test the sample for F. tularensis or see if it grows from the sample.

How is tularemia treated?

Treatment of tularemia involves broad-spectrum antibiotics, either given to you by a healthcare provider with a needle (injection) or taken by mouth (pill). You may need other treatments if you have serious complications.

It’s important to treat tularemia as soon as possible. Your provider may give you antibiotics before your test results are back to keep you from getting seriously ill.

Is tularemia curable in humans?

Yes, tularemia is curable in humans. Antibiotics can kill the bacteria that causes tularemia.

What medications are used to treat tularemia?

Antibiotics used to treat tularemia include:

• Streptomycin.
• Gentamicin.
• Doxycycline.
• Azithromycin.
• Ciprofloxacin or levofloxacin.

How do I take care of myself/manage symptoms?

It’s important to take all of your prescribed medication until it’s gone unless otherwise directed by your provider. If you stop taking antibiotics too early, some bacteria could remain in your body, causing you to become sick again.

In addition to prescribed antibiotics, you may be able to manage some symptoms of tularemia at home. Ask your healthcare provider if there are over-the-counter (OTC) medications or other therapies that are safe for treating your symptoms.

How can I reduce my risk of tularemia?

You can reduce your risk of tularemia by protecting yourself and your pets from bug bites, safely handling animals and cooking meat to safe temperatures.

• When possible, wear clothing that covers as much skin as you can while outdoors, especially in long grass or wooded areas. Wear bug spray with DEET.
• Check yourself and your pets for ticks after being outside. If possible, have someone else check in places you can’t easily see, like your scalp.
• Ask your veterinarian how to prevent ticks on your pets. Cats that go outdoors can get infected with tularemia.
• Supervise your pets when they go outside. Bites from other animals can spread tularemia.
• Wear gloves when handling animals (living or dead). Never pick up a wild animal with your bare hands. Wash your hands thoroughly after handling animals, even if you wore gloves.
• Cook meat to safe temperatures and always wash your hands, surfaces and utensils after preparing food. Game meat can carry bacteria that cause tularemia.
• Don’t drink untreated water.
• Avoid mowing or using other machinery around animal carcasses if possible. Don’t hit any animal with machinery if it’s possible to avoid it. Wearing a mask while using a mower or agricultural equipment may help prevent breathing in any aerosolized particles, but more research is necessary to confirm this.
• If you’ve had a possible exposure to tularemia, ask your healthcare provider whether you should take antibiotics to prevent getting sick.

What can I expect if I have tularemia?

Most people with tularemia make a full recovery. You can expect to be on antibiotics for 10 to 21 days.

Depending on your symptoms, your healthcare provider may monitor you closely for the first couple of days of treatment. If your symptoms began a while before starting antibiotics, you could have serious complications.

Some people’s symptoms come back after they feel better (relapse). If this happens to you, you may have to take another course of antibiotics.

How long does tularemia last?

Treatment for tularemia lasts for two to three weeks, but it could take longer than that to feel completely better. Sometimes rashes from tularemia leave permanent scars on your skin.

When can I go back to work/school?

Tularemia doesn’t spread between people, so you should be able to go back to work or school whenever you feel able.

Outlook for tularemia

With prompt treatment, the outlook for tularemia is good. Less than 1% of cases of tularemia are fatal when treated quickly with antibiotics.

Complications of tularemia

Complications of tularemia usually happen in connection with pneumonic or typhoidal tularemia, and include:

• Acute respiratory distress syndrome (ARDS).
• Brain inflammation (meningitis or meningoencephalitis).
• Heart inflammation (myocarditis, pericarditis or endocarditis).
• Bone, bone marrow or joint inflammation (osteomyelitis or arthritis).
• Liver inflammation (hepatitis).
• Kidney (renal) failure.
• Internal bleeding (hemorrhage).

Can you recover from tularemia without antibiotics?

Some people might recover from tularemia without antibiotics, but the risk for severe complications, including organ damage, is high. Up to 30% of untreated cases of type A tularemia are fatal.

When should I see my healthcare provider?

See a healthcare provider if you:

• Have symptoms of tularemia.
• Think you had an exposure to tularemia. A healthcare provider might recommend taking antibiotics to prevent getting sick.
• If tularemia symptoms come back during treatment or after you complete treatment.

When should I go to the ER?

Go to the nearest ER if you have any symptoms of serious illness:

• Fever over 103 F (39.4 C).
• Confusion or other mental changes.
• Blood in your vomit or poop (stool).
• Coughing up blood.
• Bluish skin, lips or nails (hypoxia).
• Severe abdominal pain.
• Severe or sudden shortness of breath.

What questions should I ask my doctor?

• How do I take my medication?
• How can I treat my symptoms at home?
• When should I follow up with you?
• When should I go to the ER?

Has tularemia been used as a biological weapon?

Since it’s highly infectious, there are concerns that F. tularensis, the bacterium that causes tularemia, could be used as a biological weapon. However, there are no records or confirmed reports of biological weapon-related tularemia outbreaks.

A note from Cleveland Clinic

Tularemia is a rare but serious illness. If you think you were exposed to or have symptoms of tularemia, see a healthcare provider right away. With quick treatment, you can make a full recovery.