Symptoms of tularemia in adults

Symptoms of tularemia appear after an incubation period, which ranges from several hours to 3 weeks (on average 3-7 days).

According to the classification of G.P. Rudnev (1960), several forms of tularemia are distinguished.

Forms of tularemia and the mechanism of infection

Clinical form	Mechanism of infection
Bubonic (glandular)	Contact
Ulcerative-bubonic (ulceroglandular)	Transmissible
Oculo-bubonic (oculoglandular)	Aerosol
Anginous-bubonic (anginal-glandular)	Fecal-oral
Abdominal (gastrointestinal)	Fecal-oral
Pulmonary with bronchitis and pneumonic variants (thoracic)	Aerosol
Generalized or primary septic	-

Depending on the severity of the infectious process, mild, moderate and severe forms of tularemia are distinguished.

According to the duration of the course, there are acute (up to 3 months), protracted (up to 6 months), recurrent tularemia and, in addition, inapparent (when symptoms of tularemia are absent), which is detected mainly during epidemic outbreaks during laboratory testing.

Tularemia occurs cyclically. The following periods of the disease are distinguished: incubation, initial, peak period and recovery.

Symptoms of tularemia in the initial period are the same for all clinical forms. Typically, the onset is acute: with chills, fever and symptoms of intoxication. The temperature rises to 38-40 °C and higher within a few hours. At the same time, headache, dizziness, weakness, fatigue, muscle pain (especially in the lumbar region and calf muscles), loss of appetite, sleep disturbances, and increased sweating occur. Bradycardia, hypotension, and hepatosplenomegaly are possible.

The initial period lasts 2-3 days. Later, signs characteristic of a particular clinical form appear, but the common symptoms for all forms are fever, the characteristic appearance of the patient, and intoxication.

The duration of the febrile period is 2-3 weeks (from 5-7 to 30 days), but sometimes, with a recurrent course or the addition of complications, it can be extended to several months. The nature of the temperature curve can be different: remittent (mainly), irregularly intermittent, constant, undulating. The recovery period can be accompanied by prolonged subfebrile condition.

The appearance of patients is characteristic: the face is puffy and hyperemic, in severe cases - bluish-purple (especially around the eyes, lips, earlobes). Often a pale triangle is noted around the chin, signs of conjunctivitis, injection of scleral vessels, pinpoint hemorrhages on the mucous membrane of the oral cavity are detected. Nosebleeds are possible. Patients are euphoric.

On the skin, from the third day of the disease, a rash of erythematous, papular or petechial nature may appear, which resolves with lamellar and/or pityriasis-like peeling, pigmentation. In elderly people, nodular erythema may occur.

The most characteristic symptoms of tularemia are lymphadenitis of various localizations, observed in all forms of the disease.

The bubonic (glandular) form occurs as a result of contact or transmission infection. The bubo is usually localized in the area of the inguinal, femoral, elbow and axillary lymph nodes. Lymphadenitis is detected 2-3 days after the onset of the disease. Gradually increasing, the lymph nodes reach their maximum size by the 5th-8th day of the disease. If a group of regional lymph nodes is involved in the process, a conglomerate with signs of periadenitis may form. The size of the bubo can vary from the size of a hazelnut to 10 cm. The color of the skin above the bubo is initially unchanged; mobility is limited, pain is weak. The evolution of the bubo is different. Most often, complete resorption (from the end of the 2nd week) or sclerosis occurs. Less common are suppuration (from the end of the second - beginning of the third week) and spontaneous opening of the bubo with subsequent scarring. In this case, the skin above it turns red, the lymph node fuses with the skin and becomes more painful, and fluctuation occurs. Subsequently, a fistula is formed, through which thick creamy pus is released. In this case, the healing or resorption of the bubo occurs very slowly, in a wave-like manner, often with scarring and sclerosis of the lymph node. In this regard, in case of suppuration and clear fluctuation, it is recommended to open the node: this accelerates healing.

A distinction is made between primary (due to lymphogenous spread of the pathogen) and secondary (due to hematogenous spread of the pathogen) buboes. Secondary buboes are not associated with the entry gate, they are smaller than primary ones, do not suppurate and completely resolve.

The outcome and duration of the bubonic form of tularemia depend on the timeliness of specific therapy. Without full treatment, symptoms of tularemia may persist for 3-4 months or more.

In the ulcerative-bubonic (ulceroglandular) form of tularemia, unlike the bubonic, a primary affect is formed at the site of pathogen penetration. It usually develops with transmissible, less often - with contact infection. The local process goes through the stages of a spot, papule, vesicle and pustule, which, opening, is transformed into a painless small (5-7 mm) ulcer. Its edges are raised, the discharge is serous-purulent, scanty. In 15% of cases, the ulcer remains unnoticed. The usual localization of the primary affect is open parts of the body (neck, forearms, shins).

The local skin process is accompanied by enlargement, soreness of regional lymph nodes and formation of a bubo, typical symptoms of tularemia are characteristic. Lymphangitis is not characteristic of the ulcerative-bubonic form of tularemia. The ulcer heals under the crust rather slowly - within 2-3 weeks or longer. After the crust is rejected, a depigmented spot or scar remains.

The angina-bubonic (angina-glandular) form occurs when contaminated with food or water, in particular when eating undercooked meat (usually hare). The primary affect is located on the tonsils (usually on one of them) or on the mucous membrane of the back wall of the pharynx, palate. Specific angina is characterized by hyperemia with a bluish tint and swelling of the tonsil, a grayish-white insular or filmy coating. The coating is difficult to remove and resembles diphtheria, but it does not spread beyond the tonsils. Under the coating, after a few days, one or more slowly healing, often scarring ulcers appear. In some cases, the pathological process on the mucous membrane of the pharynx is limited to symptoms of catarrhal angina. Petechiae often occur. Simultaneously with the development of angina, cervical (usually submandibular) lymphadenitis is observed with all the signs of a tularemia bubo (size - from a walnut to a chicken egg). Sometimes the formation of a bubo does not coincide in time with the development of the process on the tonsils, lymphadenitis develops later. With massive infection, a combination of angina-bubonic and abdominal forms of tularemia is possible, especially in people with low acidity of gastric juice. The disease occurs with high temperature and intoxication.

The duration of tularemia angina is from 8 to 24 days. In severe cases, specific antibodies are detected late, which complicates the diagnosis of the disease.

The abdominal (gastrointestinal) form, as well as the angina-bubonic, occurs with alimentary infection. This is one of the rare, but very severe forms of the disease. It is characterized by high temperature and severe intoxication. Typical symptoms of tularemia appear: intense aching or cramping, diffuse or localized in a certain area pain in the abdomen, often imitating the picture of an acute abdomen. The tongue is coated with a gray-white coating, dryish. Nausea, vomiting, flatulence, enlargement of the liver and spleen are possible. From the very beginning of the disease, stool retention or loose stools without pathological impurities are observed.

Cases of ulcerative lesions of the mucous membrane of the ileum and small intestine, pyloric part of the stomach and duodenum are described. Sometimes it is possible to palpate enlarged and dense mesenteric lymph nodes or their conglomerates. Lymphadenitis may be accompanied by symptoms of peritoneal irritation, and with suppuration and opening of the lymph nodes, peritonitis and intestinal bleeding may develop.

The oculo-bubonic (oculoglandular, ophthalmic) form occurs when infected through the conjunctiva, when the pathogen enters the eye through contaminated hands, airborne dust, when washing with water from infected sources or when bathing. The ophthalmic form of tularemia is quite severe, but it is observed relatively rarely (1-2% of cases).

The development of acute specific, often unilateral conjunctivitis with severe lacrimation and swelling of the eyelids, pronounced swelling of the transitional fold of the conjunctiva, mucopurulent discharge is characteristic. Yellowish-white nodules the size of a millet grain, ulcers are noted on the mucous membrane of the lower eyelid. Vision is not affected. The process is accompanied by an increase and slight soreness of the parotid, anterior cervical and submandibular lymph nodes. The duration of the disease is from 3 weeks to 3 months or longer. The development of complications such as dacryocystitis (inflammation of the lacrimal sac), phlegmon, keratitis, corneal perforation is possible.

The pulmonary (thoracic) form with a primary inflammatory process in the lungs is recorded in 11-30% of tularemia cases. Infection occurs through airborne dust (by inhaling infected dust during agricultural work).

There are two types of pulmonary form: bronchitis and pneumonic.

The bronchitis variant, in which the lymph nodes are affected, is relatively mild, with subfebrile body temperature, dry cough, pain behind the breastbone (with the development of tracheitis). Hard breathing and scattered dry wheezing are heard. X-ray examination reveals an increase in tracheobronchial lymph nodes. Symptoms of tularemia disappear after 10-14 days.

The pneumonia variant is more severe and lasts longer (up to 2 months or more), with a tendency to relapse and abscess formation. A clinical picture of pneumonia (focal, segmental, lobar or disseminated) is detected, which does not have any pathognomonic signs.

Physical findings are scanty (dullness of percussion sound, dry and moist rales of various sizes) and appear late. The pleura may be involved in the pathological process. Hepato- and splenomegaly are often detected.

Radiologically, an increase in the pulmonary pattern (perivascular and peribronchial infiltrates), an increase in the hilar, paratracheal and mediastinal lymph nodes, and pleural effusion are determined. All these signs can be detected no earlier than the 7th day of the disease. As a result of necrosis of the affected areas of the lung, cavities of various sizes (tularemia caverns) can form.

The primary pulmonary form of tularemia should be distinguished from the secondary form, which develops metastatically and can join any form of the disease at a later date.

Symptoms of pulmonary tularemia disappear completely with timely and correct treatment; mortality does not exceed tenths of a percent (in the past - up to 5%), but is characterized by a long (up to 2 months) course, development of abscesses, bronchiectasis.

Relapses, as well as a protracted course, often occur with late initiation or inadequate antibacterial therapy. Their development is due to the long-term persistence of the pathogen. Early (after 3-5 weeks) and late (after several months and even years) relapses are distinguished. Bubonic tularemia recurs more often: lymphadenitis localized near the primary bubo or not far from it, minor intoxication, weakness, sweating, sleep disturbance. Fever is absent; subfebrile condition is sometimes noted. The size of the affected lymph node is usually smaller than in the primary disease; suppuration occurs much less frequently.

Complications are more often observed in the generalized form of tularemia. Development of infectious toxic shock, meningitis, meningoencephalitis, pericarditis, myocardial dystrophy, polyarthritis, autonomic neuroses, peritonitis (due to suppuration and spontaneous opening of the mesenteric lymph nodes in the abdominal form), corneal perforation, bronchiectasis, abscess and gangrene of the lungs (in the pneumonic form) is possible. The course of any form can be complicated by tularemia pneumonia.