PracticeUpdate Dermatology May 2019

EXPERT OPINION 21

Depending on the transmission route, six clinical types of tularemia have been described: glandular, ulceroglandular, ocu- loglandular, oropharyngeal, typhoidal, and pulmonary disease. The most common clinical type is the ulceroglandular type, whereas oculoglandular tularemia is very rare. However, the most common clinical type in Turkey and Europe is the oropharyn- geal type. Polat et al, in their review of 168 cases of tularemia from Turkey, found that 149 (88.69%) had the oropharyngeal type, 12 (7.73%) had the ulceroglandular type, 5 (2.9%) had the oculoglandular type, and 2 (0.59%) had the pulmonary type. 5 Sec- ondary skin manifestations were found in 26 patients (15.47%). Sweet syndrome (SS) was found in 11 patients (6.54%), most of whom presented with the oropharyngeal form, while erythema nodosum (EN) was found in 7 patients (4.16%), dermatitis in 2 (1.19%), urticaria in 2 (1.19%), acneiform erup- tions in 1 (0.59%), vasculitis-like eruptions in 1 (0.59%), and SS + EN in 1 (0.59%). Patients with the oropharyngeal form had a statis- tically significant (P < .001) higher number

of skin findings than patients with the other forms. The authors concluded that derma- tologists working in endemic regions must be aware of the varied clinical presenta- tions of tularemia. The diagnosis of tularemia may be con- firmed serologically (although early testing may be negative), culture (warning the lab- oratory to prevent accidental inhalation and pneumonic tularemia in laboratory workers), 3 or by PCR.1 Therapy focuses on aminoglycosides and fluoroquinolones; caution is advised regarding tetracyclines (because of they are bacteriostatic, there is a high relapse rate upon discontinuation). Incision and drainage of involved lymph nodes may be necessary. 3 Because of the concern of tularemia as a bioterrorist threat, there is current research on developing a vaccine for general use. 6 A diagnosis cannot be made unless it is thought of. Although I hope to never see tularemia, especially if due to bioterrorism, hopefully, I will recognize it if need be.

Point to Remember: Tularemia may be present in a primary dermatological disease (such as the ulceroglandular form), with or without secondary dermatoses (erythema multiforme, Sweet syndrome, erythema nodosum). Disclaimer: First published on Dr. Warren Heymann’s Dermatology Insights and Inquiries website on September 24, 2018. Republished with permission. References 1. Coates SJ, Briggs B, Cordoro KM. Tularemia- induced erythema multiforme minor in an 11-year-old girl. Pediatr Dermatol 2018;35(4):478-481. 2. Stidham RA, et al. Epidemiological review outbreaks.8eb0b55f377abc2d250314bbb8fc9d6d. 3. Snowden J, Simonsen KA. Tularemia. StatPearls [Internet). Treasure Island (FL): StatPearls Publishing. Last updated February 6, 2019. 4. Faber M, Heuner K, Jacob D, Grunow R. Tularemia in Germany – a re-emerging zoonosis. Front Cell Infect Microbiol 2018;8:40. 5. Polat M, Karapınar T, Sırmatel F. Dermatological aspects of tularemia: a study of 168 cases. Clin Exp Dermatol 2018;43(7):770-774. 6. Putzova D, Senitkova I, Stulik J. Tularemia vaccines. Folia Microbiol 2016;61(6):495-504. www.practiceupdate.com/c/78938  of Francisella tularensis: a case study in the complications of dual diseases. PLoS Curr 2018 Jan 18;10. doi: 10.1371/currents.

VOL. 3 • NO. 2 • 2019