sábado, 20 de diciembre de 2014

Tularemia in Children, Turkey, September 2009–November 2012 - Volume 21, Number 1—January 2015 - Emerging Infectious Disease journal - CDC

full-text ►

Tularemia in Children, Turkey, September 2009–November 2012 - Volume 21, Number 1—January 2015 - Emerging Infectious Disease journal - CDC


Volume 21, Number 1—January 2015


Tularemia in Children, Turkey, September 2009–November 2012

Hasan Tezer, Aslınur Ozkaya-ParlakayComments to Author , Hakan Aykan, Mustafa Erkocoglu, Belgin Gülhan, Ahmet Demir, Saliha Kanik-Yuksek, Anil Tapisiz, Meltem Polat, Soner Kara, Ilker Devrim, and Selcuk Kilic
Author affiliations: Gazi University School of Medicine, Ankara, Turkey (H. Tezer, A. Tapisiz, M. Polat, S. Kara);Ankara Hematology Oncology Children’s Training and Research Hospital, Ankara (A. Ozkaya-Parlakay, H. Aykan, M. Erkocoglu, B. Gülhan, A. Demir, S. Kanik-Yuksek)Dr. Behcet Uz Children's Training and Research Hospital, Izmir, Turkey (I. Devrim)Public Health Institution of Turkey, Ankara (S. Kilic)


Tularemia, a zoonotic disease caused by Francisella tularensis, is found throughout most of the Northern Hemisphere. It is not well known and is often misdiagnosed in children. Our aim with this study was to evaluate the diagnosis, treatment, and prognosis for 100 children with tularemia in Turkey. The mean patient age was 10.1 ± 3.5 years (range 3–18 years), and most (63%) patients were male. The most common physical signs and laboratory findings were cervical lymphadenopathy (92%) and elevated erythrocyte sedimentation rate (89%). Treatment response was higher and rate of relapse lower for children 5–10 years of age than for those in other age groups. Associated with treatment failure were female sex, treatment delay of ≥16 days, and use of doxycycline. Tularemia is endemic to Turkey, and the number of cases has been increasing among children as well as adults.
Tularemia, caused by Francisella tularensis, is a potentially fatal, multisystemic disease in humans. Tularemia occurs throughout most of the Northern Hemisphere, and the number of cases is increasing in various parts of Europe, especially in the Balkans, Turkey, and Scandinavian countries. There are 4 recognized subspecies of F. tularensis, which differ in their pathogenicity and geographic distribution: tularensis (type A), holarctica (type B),novicida, and mediasiatica. Among them, subspecies tularensis and holarctica are of particular clinical and epidemiologic relevance (14). Although the highly virulent subspecies tularensis is restricted almost exclusively to North America, subspecies holarctica is found in Europe, Asia, and North America and represents the most common subspecies involved in human and animal infection (4).
The clinical forms of tularemia are ulceroglandular or glandular, oculoglandular, oropharyngeal, respiratory, and typhoidal (1). Each form somehow reflects the mode of transmission. The clinical picture and severity of the disease in humans vary considerably depending on the route of infection, the virulence of the causative organism, and the immune status of the host. The ulceroglandular form has been reported as the most prevalent clinical form of the disease in northern Europe, whereas the oropharyngeal form has been most commonly reported in Turkey, Bulgaria, and Kosovo and is attributed to the consumption of contaminated water and food (510).
Tularemia is endemic to Turkey, and most cases are reported to occur in late summer or early autumn (10). Various studies on clinical course, treatment, and treatment failure in elderly patients are available in the literature (7,1012). However, the clinical course of tularemia in children is not well known, and cases in children are often misdiagnosed. Our aim was to demonstrate the clinical features and outcomes for children with tularemia.

Dr Tezer is a physician at the Gazi University School of Medicine hospital. His research interest is zoonotic diseases, especially tularemia and Crimean-Congo hemorrhagic fever.


  1. World Health Organization. WHO guidelines on tularemia [cited 2013 Jul 22].http://whqlibdoc.who.int/publications/2007/9789241547376_eng.pdf
  2. Sjöstedt ATularemia: history, epidemiology, pathogen physiology, and clinical manifestations. Ann N Y Acad Sci2007;1105:129DOIPubMed
  3. Eliasson HBroman TForsman MBäck ETularemia: current epidemiology and disease management. Infect Dis Clin North Am2006;20:289311.DOIPubMed
  4. Ellis JOyston PCGreen MTitball RWTularemia. Clin Microbiol Rev2002;15:63146 and. DOIPubMed
  5. Tärnvik APriebe HSGrunow RTularaemia in Europe: an epidemiological overview. Scand J Infect Dis2004;36:3505DOIPubMed
  6. Helvaci SGedikoğlu SAkalin HOral HBTularemia in Bursa, Turkey: 205 cases in ten years. Eur J Epidemiol2000;16:2716DOIPubMed
  7. Reintjes RDedushaj IGjini AJorgensen TRCotter BLieftucht ATularemia outbreak investigation in Kosovo: case control and environmental studies. Emerg Infect Dis2002;8:6973DOIPubMed
  8. Komitova RNenova RPadeshki PIvanov IPopov VPetrov PTularemia in Bulgaria 2003–2004. J Infect Dev Ctries2010;4:68994 .PubMed
  9. Christova IVelinov TKantardjiev TGalev ATularaemia outbreak in Bulgaria. Scand J Infect Dis2004;36:7859DOIPubMed
  10. Kılıç SA general overview of Francisella tularensis and the epidemiology of tularemia in Turkey [in Turkish]Flora2010;15:3758.
  11. Celebi GBaruönü FAyoğlu FCinar FKaradenizli ACelebi GTularemia, a reemerging disease in northwest Turkey: epidemiological investigation and evaluation of treatment responses. Jpn J Infect Dis2006;59:22934 .PubMed
  12. Ulu-Kilic AGulen GSezen FKilic SSencan ITularemia in Central Anatolia. Infection2013;41:3919 and. DOIPubMed
  13. Sjöstedt AKuoppa KJohansson ASandström GThe 17 kDa lipoprotein and encoding gene of Francisella tularensis LVS are conserved in 241 strains of Francisella tularensis. Microb Pathog1992;13:2439DOIPubMed
  14. Broekhuijsen MLarsson PJohansson ABystrom MEriksson ULarsson EGenome-wide DNA microarray analysis of Francisella tularensis strains demonstrates extensive genetic conservation within the species but identifies regions that are unique to the highly virulent F. tularensis subsp.tularensis. J Clin Microbiol2003;41:292431DOIPubMed
  15. Arikan OKKoç CBozdoğan O. Tularemia presenting as tonsillopharyngitis and cervical lymphadenitis: a case report and review of the literature.Eur Arch Otorhinolaryngol. 2003; 260: 298–300. PMID: 12883950
  16. Senol MOzcan AKarincaoglu YAydin AOzerol IHTularemia: a case transmitted from a sheep. Cutis1999;63:4951 .PubMed
  17. Celebi SHacimustafaoglu MGedikoglu STularemia in children. Indian J Pediatr2008;75:112932 and. DOIPubMed
  18. Eliasson HLindbäck JNuorti JPArneborn MGiesecke JTegnell AThe 2000 tularemia outbreak: a case–control study of risk factors in disease-endemic and emergent areas, Sweden. Emerg Infect Dis2002;8:95660DOIPubMed
  19. Larssen KWAfset JEHeier BTKrogh THandeland KVikøren T,et al. Outbreak of tularaemia in central Norway, January to March 2011. Euro Surveill. 2011;16. pii:19828. PMID: 21489376
  20. Ozdemir DSencan IAnnakkaya ANKaradenizli AGuclu ESert EComparison of the 2000 and 2005 outbreaks of tularemia in the Duzce region of Turkey. Jpn J Infect Dis2007;60:512 .PubMed
  21. Meriç MSayan MWillke AGedikoğlu SA small water-borne tularemia outbreak [in Turkish]Mikrobiyol Bul2008;42:4959 .PubMed
  22. Ulu Kılıç AKılıç SSencan ICiçek Şentürk GGürbüz YTütüncü EEA water-borne tularemia outbreak caused by Francisella tularensis subspeciesholarctica in Central Anatolia region [in Turkish]Mikrobiyol Bul2011;45:23447 .PubMed
  23. Syrjälä HKarvonen JSalminen ASkin manifestations of tularemia: a study of 88 cases in northern Finland during 16 years (1967–1983). Acta Derm Venereol1984;64:5136 .PubMed
  24. Cerný ZSkin manifestations of tularemia. Int J Dermatol1994;33:46870DOIPubMed
  25. Jounio URenko MUhari MAn outbreak of holarctica-type tularemia in pediatric patients. Pediatr Infect Dis J2010;29:1602DOIPubMed
  26. Johansson ABerglund LEriksson UGöransson IWollin RForsman MComparative analysis of PCR versus culture for diagnosis of ulceroglandular tularemia. J Clin Microbiol2000;38:226 .PubMed
  27. Anda PSegura del Pozo JDíaz García JMEscudero RGarcía Peña FJLópez Velasco MCWaterborne outbreak of tularemia associated with crayfish fishing. Emerg Infect Dis2001;7:57582DOIPubMed
  28. Willke AMeric MGrunow RSayan MFinke EJSplettstösser W, et al. An outbreak of oropharyngeal tularaemia linked to natural spring water. J Med Microbiol. 2009;58:112–6.
  29. Meric MWillke AFinke EJGrunow RSayan MErdogan SEvaluation of clinical, laboratory, and therapeutic features of 145 tularemia cases: the role of quinolones in oropharyngeal tularemia. APMIS2008;116:6673DOIPubMed
  30. Celebi B, Yeşilyurt M. Evaluation of a commercial immunochromatographic assay for the serologic diagnosis of tularemia. Diagn Microbiol Infect Dis.2012;74:15 Kiliç SDOIPubMed
  31. Uyar MCengiz BUnlü MCelebi BKılıç SEryılmaz AEvaluation of the oropharyngeal tularemia cases admitted to our hospital from the provinces of Central Anatolia [in Turkish]Mikrobiyol Bul2011;45:5866 .PubMed
  32. Akıncı EÜlgen FKılıç SYılmaz SYıldız SÖzdemir BEvaluation of tularemia cases originated from Central Anatolia, Turkey [in Turkish].Mikrobiyol Bul2011;45:7624 .PubMed
  33. Pérez-Castrillón JLBachiller-Luque PMartín-Luquero MMena-Martín FJHerreros VTularemia epidemic in northwestern Spain: clinical description and therapeutic response. Clin Infect Dis2001;33:5736DOIPubMed
  34. Uhari MSyrjälä HSalminen ATularemia in children caused by Francisella tularensis biovar palaearctica. Pediatr Infect Dis J1990;9:803 .DOIPubMed



Suggested citation for this article: Tezer H, Ozkaya-Parlakay A, Aykan H, Erkocoglu M, Gülhan B, Demir A, et al. Tularemia in children, Turkey, September 2009–November 2012. Emerg Infect Dis [Internet]. 2015 Jan [date cited]. http://dx.doi.org/10.3201/eid2101.131127
DOI: 10.3201/eid2101.131127

No hay comentarios:

Publicar un comentario