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October 3, 2024
Background
To date, 18 cases of tularemia have been reported to the Nebraska Department of Health and Human Services in
2024, an increase above the annual average of 10.8 cases over the last five years (2019–2023). Of particular
concern is an increase in reported cases during the month of September. In contrast with the previous five years
in which only one case was reported on average, seven cases have been reported to date in September 2024. Of
these, four (57%) have been classified as the pneumonic form of tularemia, which is characterized by cough,
chest pain, and difficulty breathing. This results from inhaling dusts or aerosols containing Francisella
tularensis. Inhalation of infective aerosols can be generated while handling animal hides, cleaning areas
contaminated with dried rodent carcasses, moving contaminated grain, or by mowing over infected animal
carcasses. Healthcare providers should keep tularemia as a differential diagnosis for individuals presenting with
pneumonia-like symptoms particularly for patients with a compatible exposure history.
Tularemia
Tularemia is caused by the bacteria Francisella tularensis. This bacterium is found in nature in rabbits,
muskrats, prairie dogs, and other rodents. Human infection occurs through several routes, including tick or deer
fly bites, skin contact with infected animals, bites from infected cats, ingestion of contaminated water, or
inhalation of contaminated dusts or aerosols.
Disease signs and symptoms vary depending on how the bacteria enters the body, with illness severity ranging
from mild to life-threatening. All forms are accompanied by fever, which can be as high as 104°F. Forms of
tularemia include:
• Ulceroglandular: Typically occurs following a tick or deer fly bite or after handling of an infected
animal. A skin ulcer appears at the site where the bacteria entered the body. The ulcer is accompanied by
swelling of regional lymph glands, usually in the armpit or groin.
• Glandular: Similar to ulceroglandular tularemia but without an ulcer. Also generally acquired through
the bite of an infected tick or deer fly or from handling sick or dead infected animals.
• Oculoglandular: Occurs when the bacteria enter through the eye. This can occur when a person is
butchering an infected animal and touches their eyes. Symptoms include irritation and inflammation of
the eye and swelling of lymph glands in front of the ear.
• Oropharyngeal: Results from eating or drinking contaminated food or water. Patients with
oropharyngeal tularemia might experience sore throat, mouth ulcers, tonsillitis, and swelling of lymph
glands in the neck.
• Pneumonic: This is the most serious form of tularemia. Symptoms include cough, chest pain, and
difficulty breathing. This form results from breathing dusts or aerosols containing the organism. It can
also occur when other forms of tularemia (e.g., ulceroglandular) are left untreated and the bacteria
spread through the bloodstream to the lungs.
• Typhoidal: Characterized by any combination of the general symptoms (which may include fever,
chills, headache, malaise, fatigue, lack of appetite, muscle aches, chest discomfort, cough, vomiting,
diarrhea, and/or abdominal pain) without the localizing symptoms of other syndromes.
Continued: https://dhhs.ne.gov/han%20Documents/UPDATE10032024.pdf
October 3, 2024
Background
To date, 18 cases of tularemia have been reported to the Nebraska Department of Health and Human Services in
2024, an increase above the annual average of 10.8 cases over the last five years (2019–2023). Of particular
concern is an increase in reported cases during the month of September. In contrast with the previous five years
in which only one case was reported on average, seven cases have been reported to date in September 2024. Of
these, four (57%) have been classified as the pneumonic form of tularemia, which is characterized by cough,
chest pain, and difficulty breathing. This results from inhaling dusts or aerosols containing Francisella
tularensis. Inhalation of infective aerosols can be generated while handling animal hides, cleaning areas
contaminated with dried rodent carcasses, moving contaminated grain, or by mowing over infected animal
carcasses. Healthcare providers should keep tularemia as a differential diagnosis for individuals presenting with
pneumonia-like symptoms particularly for patients with a compatible exposure history.
Tularemia
Tularemia is caused by the bacteria Francisella tularensis. This bacterium is found in nature in rabbits,
muskrats, prairie dogs, and other rodents. Human infection occurs through several routes, including tick or deer
fly bites, skin contact with infected animals, bites from infected cats, ingestion of contaminated water, or
inhalation of contaminated dusts or aerosols.
Disease signs and symptoms vary depending on how the bacteria enters the body, with illness severity ranging
from mild to life-threatening. All forms are accompanied by fever, which can be as high as 104°F. Forms of
tularemia include:
• Ulceroglandular: Typically occurs following a tick or deer fly bite or after handling of an infected
animal. A skin ulcer appears at the site where the bacteria entered the body. The ulcer is accompanied by
swelling of regional lymph glands, usually in the armpit or groin.
• Glandular: Similar to ulceroglandular tularemia but without an ulcer. Also generally acquired through
the bite of an infected tick or deer fly or from handling sick or dead infected animals.
• Oculoglandular: Occurs when the bacteria enter through the eye. This can occur when a person is
butchering an infected animal and touches their eyes. Symptoms include irritation and inflammation of
the eye and swelling of lymph glands in front of the ear.
• Oropharyngeal: Results from eating or drinking contaminated food or water. Patients with
oropharyngeal tularemia might experience sore throat, mouth ulcers, tonsillitis, and swelling of lymph
glands in the neck.
• Pneumonic: This is the most serious form of tularemia. Symptoms include cough, chest pain, and
difficulty breathing. This form results from breathing dusts or aerosols containing the organism. It can
also occur when other forms of tularemia (e.g., ulceroglandular) are left untreated and the bacteria
spread through the bloodstream to the lungs.
• Typhoidal: Characterized by any combination of the general symptoms (which may include fever,
chills, headache, malaise, fatigue, lack of appetite, muscle aches, chest discomfort, cough, vomiting,
diarrhea, and/or abdominal pain) without the localizing symptoms of other syndromes.
Continued: https://dhhs.ne.gov/han%20Documents/UPDATE10032024.pdf