[Evaluation of the oropharyngeal tularemia cases admitted to our hospital from the provinces of Central Anatolia].

Tularemia caused by the bacterium Francisella tularensis is a zoonotic infection which has re-emerged in Turkey in recent years as water-borne endemics. Oropharyngeal form is the most frequently reported form of the disease from Turkey. The aim of this study was to evaluate the clinical and laboratory findings of oropharyngeal tularemia patients admitted to ear, nose & throat outpatient clinic between January-March 2010. A total of 10 patients (age range: 16-80 years, mean age: 43.9 years; nine were male) inhabiting in the provinces in Central Anatolia, Turkey, were admitted to our hospital with the complaints of fever, sore throat and painful cervical lump. They have been previously diagnosed as tonsillo-pharyngitis at different medical centers and empirical antibiotic therapy has initiated, however, their complaints have not recovered. Endoscopic laryngoscopic examination revealed that oropharynx, larynx and hypopharynx were normal. Physical examination of the neck yielded localized fixed masses with diameters between 2-7 cm. The lesions were localized at right submandibular (n= 4), upper jugular (n=3) and one of each at left posterior cervical, left submandibular and left jugulodigastric regions. The patients were hospitalized with the pre-diagnosis of "neck mass with unknown origin" for further investigation and treatment. The mean white blood cell count of the cases was 9730 (7500-15.100) cells/µl; the mean erythrocyte sedimantation rate was 68.7 (46-85) mm3/hours and the mean C-reactive protein level was 4.3 (1.5-7.4) µg/dl. Salmonella, Brucella, Toxoplasma gondii, rubella, cytomegalovirus, herpes simplex virus, Epstein-Barr virus and viral hepatitis serology did not indicate acute infections. Serum and tissue samples were sent to Refik Saydam National Public Health Agency in order to test for tularemia, namely culture, microagglutination test (MAT), direct fluorescence antibody (DFA) test and in-house polymerase chain reaction (PCR). All of the patients (10/10) were found positive for tularemia by F.tularensis MAT yielding antibody titers of ≥ 1:640. Lymph aspirate samples could be collected from seven cases and of them 5 (71.4%) were found positive by PCR, while 3 (42.9%) were positive by DFA test. PCR which was performed with the use of RD1 primers yielded F.tularensis subsp. Holarctica. The cultures of blood, urine, lymph aspirates and throat swabs were negative for F.tularensis growth. Of 10 patients two had the history of animal contact and four had consumed fountain water. Nine of the cases were treated with 10 days streptomycin and one with doxycycline, and all were discharged with complete cure. In conclusion, tularemia should be considered in the differential diagnosis of patients with painful lumps in the neck and didn't recover with empirical antibiotic therapy directed against tonsillopharyngitis, particularly in endemic areas.