Tularemia

Tularemia is an infection you get from the bacterium Francisella tularensis (F. tularensis). It’s a zoonotic disease. That means it spreads between infected animals and people. It isn’t common — there were fewer than 200 cases in the U.S. in 2023. Most infections occur in the southcentral U.S., the Pacific Northwest and parts of Massachusetts. But experts have identified cases in other states, too. They believe climate change may be responsible for this spread.

Tularemia (pronounced “too-luh-REE-mee-uh”) can infect your:

• Lymph nodes
• Skin
• Eyes
• Throat
• Intestines (gut)
• Lungs

Your symptoms may vary depending on where the bacteria infect you. But it generally causes a fever and painfully swollen lymph nodes. These symptoms may appear a few days or up to two weeks after exposure. The infection may range from mild to life-threatening.

Other names for tularemia include:

• Rabbit fever
• Deer fly fever
• Wild hare disease
• Lawnmower tularemia

Types

Tularemia has many forms. They vary according to how you got the F. tularensis infection and what your symptoms are. They include:

• Ulceroglandular tularemia: This is the most common form. The infection usually develops from an infected tick or animal bite. It affects your skin and lymph nodes.
• Glandular tularemia: This type is similar to ulceroglandular tularemia. But it only affects your lymph nodes. It develops after a tick bite or direct contact with an animal.
• Oculoglandular tularemia: This form develops after contaminated water or body fluids get in your eye. It causes symptoms in and around your eye. It usually only affects one eye.
• Oropharyngeal tularemia: This form develops after ingesting contaminated food or water. It can also spread from your hands to your mouth. It causes a sore throat and may cause digestive symptoms.
• Pneumonic tularemia: This is the most serious form. It causes pneumonia-like symptoms. You get it from breathing in the bacteria. You can also get it from the bacteria spreading from your lungs to another part of your body.
• Typhoidal tularemia: This form causes a high fever. It can affect many parts of your body.

Symptoms of tularemia

Symptoms depend on what form you have. Most forms cause general symptoms, such as:

• Abdominal pain
• Fever
• Chills
• Headache
• Loss of appetite
• Muscle aches
• Nausea and vomiting
• Swollen lymph nodes

Depending on the type you have, you may also have symptoms like:

• Pink eye
• Skin rash
• Open skin sores (ulcers)
• Sore throat
• Painful white patches in your throat
• Cough
• Diarrhea, which may be bloody
• Confusion

Tularemia causes

The bacterium F. tularensis causes tularemia. There are two main types:

• Type A ( t. tularensis): This type causes more serious illness. It mostly exists in North America.
• Type B ( t. holarctica): This type causes milder symptoms. It exists throughout the northern hemisphere.

The most common ways in which tularemia bacteria spread from infected animals to humans are through:

• Bites from ticks, deer flies, mosquitoes and other biting insects
• Contact with certain animals, especially rabbits, hares and rodents
• Animal bites
• Touching animal tissue or bodily fluids
• Ingesting untreated water or contaminated food
• Breathing in bacteria, usually from blood or exposed tissues, like if a lawnmower runs over an animal

Tularemia isn’t contagious — there’s no evidence that it can spread directly from person to person. But it’s highly infectious. That means even coming across a small amount of bacteria can make you sick.

Risk factors

Anyone can get tularemia. But you may be at a higher risk if you:

• Work as a veterinarian, animal control officer, exterminator, farmer or in another animal-related job
• Hunt or handle uncooked meat
• Are around biting insects
• Live in areas that have higher cases of tularemia, especially Arkansas, Oklahoma, Missouri, Nebraska, South Dakota and Kansas

You’re also at a greater risk of illness if you have a weakened immune system. You may have a weakened immune system if you have:

• HIV or AIDS
• Have cancer
• Take immunosuppressants

Complications

Tularemia complications may 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 failure
• Internal bleeding
• Pneumonia
• Sepsis

These complications are more likely to develop if you have pneumonic tularemia or typhoidal tularemia.

How doctors diagnose tularemia

A healthcare provider will:

• Review your health history
• Ask about your symptoms
• Perform a physical exam, which may include looking at your lymph nodes, throat, eyes, and any bumps or sores on your skin

If they suspect tularemia, they may recommend tests to make an official diagnosis.

Tests that are used

Your provider may recommend the following tests to look for F. tularensis or see if it grows from a sample:

• Blood tests
• Lymph node biopsy
• Nasal or throat culture swab
• Pleural fluid test

How is it treated?

Your healthcare provider will prescribe broad-spectrum antibiotics to kill Francisella tularensis bacteria. These may include:

• Streptomycin
• Gentamicin
• Doxycycline
• Azithromycin
• Ciprofloxacin
• Levofloxacin
• Tetracycline
• Chloramphenicol

You may need to take them as pills by mouth. Your provider may also inject them with a needle.

It’s important to treat tularemia as soon as possible. Your provider may give you antibiotics before your test results are back. This can help keep you from getting seriously ill. Take all of your antibiotics as recommended by your provider. If you don’t finish your full course, the infection may come back and be more challenging to treat.

Can you recover without antibiotics?

Some people might recover from tularemia without antibiotics. But the risk of severe complications is high. Without treatment, tularemia may be fatal in 10% to 50% of cases.

Recovery time

You’ll need to take antibiotics for two to three weeks. But even after completing your full course of antibiotics, it may take some time before you feel completely better.

Sometimes, your symptoms may come back after you start to feel better. If this happens, you may need another course of antibiotics.

When should I see my healthcare provider?

Schedule an appointment with a healthcare provider if you have tularemia symptoms, especially if you spend a lot of time around animals. Get to the nearest emergency room (ER) if you have symptoms of serious complications, including:

• A fever over 103 degrees Fahrenheit (39.4 degrees Celsius)
• Stiff neck or neck pain
• Confusion or other mental changes
• Shortness of breath or trouble breathing
• Lightheadedness or fainting
• Racing or irregular heartbeat (heart palpitations)
• Blood in your vomit or poop
• Coughing up blood
• Bluish skin, lips or nails (hypoxia)
• Pus or discharge from a sore

During your appointment, you may want to ask questions like:

• How will you diagnose tularemia?
• If I don’t have tularemia, what other condition might I have?
• How severe is the infection?
• What antibiotics do you recommend?
• How long do I have to take antibiotics?
• How should I store my medications?
• Am I at risk for complications?
• How can I manage my symptoms at home?
• Should I schedule follow-up appointments?

What can I expect if I have tularemia?

With a quick diagnosis and prompt treatment, the outlook for tularemia is good.

The illness can be deadly. But it’s rare. The overall mortality rate is about 4%. But if you receive quick antibiotic treatment, the mortality rate is around 1%.

Depending on your symptoms, your provider may monitor you for the first few days of treatment. If you had symptoms for days or weeks before starting antibiotics, you’re at risk of developing serious complications.

Can tularemia be prevented?

The best ways to avoid getting sick are by protecting yourself and your pets:

• Wear pants and long sleeves outside, especially in long grass or wooded areas.
• Apply bug spray with DEET to your skin and clothing.
• Check yourself and your pets for ticks after being outside.
• Avoid dead wild animals.
• Ask your veterinarian about tick prevention medications, especially if your pets spend time outside.
• Protect yourself when handling animals by wearing gloves and washing your hands with soap and water afterward.
• Always wash your hands, surfaces and utensils after preparing meat.
• Cook meat to safe temperatures.

Is tularemia the same as Lyme disease?

It has similar symptoms to Lyme disease. But they affect your body in different ways.

Unlike tularemia, Lyme disease usually isn’t life-threatening.