SHM Converge Scientific Abstract ePoster Gallery-Don't Hop to Conclusions: Atypical Presentation of Tularemia in an Immunocompetent Landscaper

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A 36-year-old immunocompetent man with no significant medical history presented with one week of nocturnal fevers, rigors, cough, night sweats, and a 5 kg weight loss over one month. He had emigrated from Guatemala 18 months earlier, briefly lived in Arizona and Texas, and had worked as a local landscaper for the past year. On admission, he was febrile to 39.4°C, with coarse breath sounds bilaterally but no rash, ulcerations, chest pain, or dyspnea.<br /><br />Initial labs showed leukocytosis with neutrophilic predominance, while the chemistry panel was normal. CT imaging demonstrated mass-like opacities in both lower lobes and the left upper lobe, mediastinal and hilar lymphadenopathy, bilateral pleural effusions, and a small right lung nodule. Because of the nonspecific pulmonary and constitutional symptoms, an extensive workup was pursued, including blood/sputum/AFB cultures, viral hepatitis and HIV testing, tick-borne studies, endemic fungal testing, TB Quantiferon, Brucella, Coxiella, Aspergillus, Fungitell, rheumatologic studies, and leukemia/lymphoma flow cytometry. All were negative. Empiric antibiotics with cefepime and azithromycin, later expanded to include minocycline, did not improve his symptoms or leukocytosis.<br /><br />On hospital day 14, bronchoscopy with biopsy revealed necrotizing granulomas, and testing was positive for Francisella tularensis microDNA, with serum IgG and IgM also positive for tularemia. The diagnosis was primary pneumonic tularemia, likely related to landscaping exposure, which can aerosolize the organism during brush cutting, weed whacking, or lawn mowing.<br /><br />Treatment was changed to IV gentamicin and oral doxycycline, producing rapid clinical improvement within 2 days. He completed 10 days of therapy with full resolution of fever, leukocytosis, and symptoms. This case highlights the importance of exposure history and multidisciplinary evaluation in atypical pneumonic tularemia.

Asset Subtitle

Jonathan Pendleton

Meta Tag

Author List Anupama Sharma, Beiyi Shen, Darius Pirestani, Jonathan Pendleton, Luis Marcos Raymundo, Madeleine Wong, Nargis Jilani

Category Clinical Vignettes

Concept Primary Pneumonic Tularemia

Concept Tularemia

Concept Tularemia Serology

Concept Aminoglycosides

Concept Doxycycline

Distinguished Non-Finalist

Presenter Organization Stony Brook University Hospital

Presenting Author Jonathan Pendleton

Track Adult

Keywords

pneumonic tularemia

Francisella tularensis

necrotizing granulomas

landscaping exposure

aerosolized transmission

pulmonary opacities

mediastinal lymphadenopathy

fever and weight loss

gentamicin doxycycline

immunocompetent patient

Primary Pneumonic Tularemia

Tularemia

Tularemia Serology

Aminoglycosides

Doxycycline