Tularemia is an uncommon zoonosis causing a variety of disease processes ranging from subclinical soft-tissue infection to septic shock and death. Its virulence has led to classification as a “class A select agent” by the U.S. Department of Agriculture, with the potential for use in bioterrorism. Although it is most commonly transmitted through contact with infected rabbits or vectors such as ticks, other animals including cats, squirrels, and hamsters have also been implicated.1–3 Francisella tularensis is extremely fastidious and is rarely isolated on routine cultures. Often, Pasteurella and staphylococcal species are grown and treatment begun that does not cover F. tularensis. This scenario is further enabled through the polymicrobial flora and needle-like teeth of the feline mouth, inoculating organisms deep into soft tissue and bone. The authors have realized this perfect storm in the clinical course of a 10-year-old girl who developed a persistent hand infection complicated by F. tularensis osteomyelitis following a cat bite.
The patient presented with recurring fever to 103°F that was persistent roughly 15 days after a cat bite. Cultures obtained from the patient previously grew Pasteurella, and the patient had been treated with amoxicillin clavulanate, trimethoprim/sulfamethoxazole, and valacyclovir for herpetic whitlow, and intravenous vancomycin at admission. We began serial incision and drainage of the infected digit, and sent another culture specimen with specific emphasis for F. tularensis. This time, the results of the culture were positive and a magnetic resonance imaging scan confirmed osteomyelitis. Therapy was directed to gentamicin, which has a literature-reviewed 86 percent rate of efficacy against tularemia4; however, amputation was considered. Fortunately, she responded well and was able to maintain full dexterity of her hand at 2-month follow-up (Fig. 1) and continues to do well 6 months postoperatively.
This case describes a rare disease manifestation with a complication that has not yet been reported. It is important for plastic surgeons to be familiar with tularemia and its epidemiologic profile. A patient with recurring fever and persistent infection in the context of a cat bite and despite appropriate coverage for previous cultures necessitates an emergent workup for tularemia. Therefore, clinicians in endemic areas (Fig. 2)5,6 must maintain a high degree of clinical suspicion, as early diagnosis and management can prevent serious consequences such as osteomyelitis, amputation, or even death.
The authors received no funding for this work and have no financial interests to disclose.
James C. Yuen, M.D.
Maximilian V. Malotky, M.D.
Department of Plastic and Reconstructive Surgery
University of Arkansas for Medical Sciences
Little Rock, Ark.
1. Kravetz JD, Federman DG. Cat-associated zoonoses. Arch Intern Med.
2. Magee JS, Steele RW, Kelly NR, Jacobs RF. Tularemia transmitted by a squirrel bite. Pediatr Infect Dis J.
3. Centers for Disease Control and Prevention (CDC). Tularemia associated with a hamster bite—Colorado, 2004. MMWR Morbid Mortal Wkly Rep.
4. Enderlin G, Morales L, Jacobs RF, Cross JT. Streptomycin and alternative agents for the treatment of tularemia: Review of the literature. Clin Infect Dis.
5. McNabb SJ, Jajosky RA, Hall-Baker PA, et al. Centers for Disease Control and Prevention (CDC). Tularemia. Number of reported cases—United States and U.S. Territories, 2006. Morbid Mortal Wkly Rep.
6. McNabb SJ, Jajosky RA, Hall-Baker PA, et al. Summary of notifiable diseases—United States, 2005. MMWR Morb Mortal Wkly Rep.
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