Symptoms of tularemia in adults

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

In accordance with the classification GP. Rudnev (1960) distinguish several forms of tularemia.

Forms of tularemia and mechanism of infection

Clinical form	The mechanism of infection
Bubonic (glandular)	Contact
Ulcerative-bubonic (Ulceroglandular)	Transmissible
Glazopubonnaya (oculoglandular)	Aerosol
Anginous-bubonic (anginal-glandular)	Fecal-oral
Abdominal (gastrointestinal)	Fecal-oral
Pulmonary with bronchial and pneumonic variants (thoracic)	Aerosol
Generalized or primary septic	-

By severity of the infectious process distinguish light, moderate and severe forms of tularemia.

The duration of the flow is acute (up to 3 months), prolonged (up to 6 months), relapsing tularemia and, in addition, inapparent (when symptoms of tularemia are absent), which is found mainly during epidemic outbreaks in laboratory studies.

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

Symptoms of tularemia in the initial period are the same for all clinical forms. Typically acute onset: with chills, fever and symptoms of intoxication. The temperature rises to 38-40 ° C and above for several hours. At the same time, headache, dizziness, weakness, weakness, muscle pains (especially in the lumbar region and calf muscles), appetite impairment, sleep disorders, increased sweating. Possible bradycardia, hypotension, hepatosplenomegaly.

The duration of the initial period is 2-3 days. Later, there are signs that are characteristic of a particular clinical form, 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 recurring course or complications, it may last up to several months. The nature of the temperature curve can be different: remittent (predominantly), incorrectly intermittent, constant, undulating. The period of convalescence can be accompanied by a long subfebrile condition.

Characterized by the external appearance of patients: the face is puffy and hyperemic, in severe cases - cyanotic-purple (especially around the eyes, lips, earlobes). Often a pale triangle is marked around the chin, signs of conjunctivitis, an injection of vessels of the sclera, pinpoint hemorrhages on the mucous membrane of the oral cavity. Possible nasal bleeding. The patients are euphoric.

On the skin from the third day of the disease, there may be a rash of erythematous, papular or petechial nature, which is resolved by lamellar and (or) otreparid peeling, pigmentation. Elderly people have erythema nodosum.

The most characteristic symptoms of tularemia are lymphadenitis of different localization, which is noted in all forms of the disease.

Bubonic (glandular) form occurs as a result of contact or transmissible infection. Bubon is usually localized in the areas of the inguinal, femoral, ulnar and axillary lymph nodes. Lymphadenitis is detected 2-3 days after the onset of the disease. Gradually increasing, the lymph nodes reach a maximum size by the 5th-8th day of the disease. When involving a group of regional lymph nodes, the formation of a conglomerate with signs of periadenitis is possible. The size of the bubo can vary from the size of the hazelnut to 10 cm. The color of the skin above the bubo is not changed at first; mobility is limited, soreness is poorly expressed. The evolution of the bubo is different. Most often there is a complete resorption (from the end of the second week) or sclerosing. Less often noted suppuration (from the end of the second - the beginning of the third week) and spontaneous opening of the bubo with subsequent scarring. At the same time, the skin over him blushes, the lymph node becomes soldered to the skin and becomes more painful, and there is a fluctuation. In the future, a fistula is formed through which a thick creamy pus is secreted. In this case, the healing or resorption of the bubo occurs very slowly, wavy, often with scarring and sclerosing the lymph node. In this regard, with suppuration and clear fluctuations, it is recommended to open the node: this accelerates the healing.

Distinguish primary (due to lymphogenous spread of the pathogen) and secondary (with hematogenous spread of the pathogen) buboes. Secondary buboes are not associated with the entrance gates, they are smaller than primary ones, they are not inflated and completely dissipate.

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

In ulcerative-bubonic (ulceroglandulary) form of tularemia, in contrast to bubonic, in the place of introduction of the pathogen primary affect is formed. It usually develops in a vector-borne, less often - in contact infection. The local process passes through the stains, papules, vesicles and pustules, which, when opened, is transformed into a painless small (5-7 mm) ulcer. Its edges are raised, separated serous-purulent, poor. In 15% of cases the ulcer remains unnoticed. The usual localization of the primary affect is the open parts of the body (neck, forearms, tibia).

Local skin process is accompanied by an increase, painful regional lymph nodes and the formation of bubo, typical of the typical symptoms of tularemia. Lymphangitis for ulcerative-bubonic form of tularemia is not typical. The ulcer heals under the crust rather slowly - for 2-3 weeks and longer. After the rejection of the crust, there remains a depigmented spot or a hem.

Anginous-bubonic (anginozno-glandular) form occurs when contaminated with food or water, in particular when using insufficiently thermally processed meat (often rabbit meat). In this case, the primary affect is located on the tonsils (more often - on one of them) or on the mucosa of the posterior pharyngeal wall, the palate. Specific angina is characterized by hyperemia with a bluish tinge and swelling of the amygdala, a grayish-white island or filmy plaque. The raids are removed with difficulty and resemble diphtheria, but they do not spread beyond the tonsils. Under the plaque in a few days, there is one or several slowly healing, often scarring ulcers. In some cases, the pathological process on the pharyngeal mucosa is limited to symptoms of catarrhal angina. Petechiae often occur. Simultaneously with the development of angina, cervical (more often submandibular) lymphadenitis with all the signs of tularemia bubo is observed (sizes - from walnut to chicken egg). Sometimes the formation of bubo does not coincide with the development of the process on the tonsils, lymphadenitis is formed later. With massive infection, a combination of anginal-bubonic and abdominal forms of tularemia is possible, especially in people with a low acidity of gastric juice. The disease occurs with a high temperature and intoxication.

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

Abdominal (gastrointestinal) form, as well as anginal-bubonic, occurs when alimentary infection occurs. This is one of the rare, but very severe forms of the disease. It is characterized by high fever and marked intoxication. There are typical symptoms of tularemia: intense aching or cramping, spilled or localized in a certain area of abdominal pain, often imitating a picture of an acute abdomen. The tongue is coated with a gray-white coating, dryish. Possible nausea, vomiting, flatulence, enlarged liver and spleen. From the very beginning of the disease, a stool retention or a loose stool without pathological impurities is 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 irritation of the peritoneum, and with suppuration and opening of the lymph nodes, it is possible to develop peritonitis, intestinal bleeding.

Glazobubonnaya (oculoglandular, ophthalmic) form occurs when infection through the conjunctiva, when the pathogen enters the eye through contaminated hands, airborne, by washing with water from infected sources or when bathing. The ophthalmic form of tularemia proceeds quite hard, but it is observed comparatively rarely (1-2% of cases).

Characteristic development of acute specific, often unilateral conjunctivitis with severe lachrymation and edema of the eyelids, expressed swelling of the transitional fold of the conjunctiva, mucopurulent discharge. On the mucosa of the lower eyelid, yellowish-white nodules the size of millet grains, sores are noted. Vision does not suffer. The process is accompanied by an increase and insignificant soreness of the parotid, anterior and submandibular lymph nodes. Duration of the disease from 3 weeks to 3 months and longer. Possible development of complications such as dacryocystitis (inflammation of the lacrimal sac), phlegmon, keratitis, corneal perforation.

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

There are two variants of the pulmonary form - bronchial and pneumonic.

The bronchitis variant, in which the lymph nodes are affected, proceeds relatively easily, with subfebrile body temperature, dry cough, chest pain (with tracheitis development). Listen to hard breathing, scattered dry wheezes. Radiographic examination revealed an increase in tracheobronchial lymph nodes. Symptoms of tularemia disappear after 10-14 days.

Pneumonic variant proceeds more difficultly and more longly (up to 2 months and more), with a tendency to recurrence and abscessing. There is a clinical picture of pneumonia (focal, segmental, lobar or disseminated), which does not have any pathognomonic features.

The physical data are meager (dullness of percussion sound, different dry and wet rales) and arise late. Perhaps involvement in the pathological process of the pleura. Often find hepato- and splenomegaly.

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

From the primary pulmonary form of tularemia it is necessary to distinguish secondary, which develops metastatically and can join any form of the disease at a later date.

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

Relapses, as well as protracted course, often occur with late or incomplete antibiotic therapy. Their development is due to the persistent persistence of the pathogen. Allocate early (after 3-5 weeks) and late (after several months and even years) relapses. Bubonic tularemia often recurs: lymphadenitis, located near or near the primary bubo, minor intoxication, weakness, sweating, sleep disturbance. Fever is absent; sometimes note a subfebrile condition. The size of the affected lymph node is usually less than that of the primary disease; suppuration occurs much less often.

Complications are more common in generalized tularemia. Possible development of infectious-toxic shock, meningitis, meningoencephalitis, pericarditis, myocardial dystrophy, polyarthritis, autonomic neuroses, peritonitis (due to suppuration and spontaneous opening of mesenteric lymph nodes in the abdominal form), perforation of the cornea, bronchiectasias, abscess and gangrene of the lungs (with pneumonic form). The course of any form can be complicated by tularemia pneumonia.