Yeşilyurt Murat, Kılıç Selçuk, Cağaşar Ozlem, Celebi Bekir, Gül Serdar
Sorgun State Hospital, Infectious Diseases Clinic, Yozgat, Turkey.
Mikrobiyol Bul. 2011 Oct;45(4):746-54.
Tularemia which has a worldwide distribution, is a zoonotic infection caused by Francisella tularensis. F.tularensis can infect a wide range of animals and can be transmitted to humans in a variety of ways, the most common being by the bite of an infected arthropod vector (usually tick) in the USA and Europe. The clinical presentations have been classically divided into ulceroglandular, glandular, oculoglandular, pharyngeal, respiratory, and typhoidal tularemia depending on the route of transmission. Arthropod-borne infection generally leads to the ulceroglandular form of tularemia. In Turkey, oropharyngeal form which is related to the consumption of contaminated water, is the most common presentation of tularemia. In this report, two cases of ulceroglandular tularemia which developed as a consequence of tick bite in Yozgat province have been presented. A 33-year-old female patient was admitted to the hospital with a tender lump on the right axilla. Empiric antibiotic treatment with amoxicillin clavulanate did not lead to an improvement in the painful axillary mass. She reported a tick bite on her right shoulder before development of fever, chills and regional tender lump. On physical examination, hyperemia was seen on the shoulder, with enlarged tender right axillary lymph node. The clinical diagnosis of suspected ulceroglandular tularemia was confirmed by the seroconversion (1/160 and 1/1280 titers in acute and convelescent sera, respectively) with microagglutination test (MAT) and F.tularensis DNA positivity in lymph node aspirate by polymerase chain reaction. The agent was identified as F.tularensis subsp. holarctica based on the results of amplification of target RD1 gene. Second case, a 18-year-old male, was admitted to our hospital with a-week history of sudden onset of fever, headache, generalized aches, vomiting, nause, and tender lump on the left axilla. On physical examination, an inflammatory eschar was seen on his scalp with enlarged cervical lymph node on left side. The tick, which has removed from the scalp lesion by the patient himself was identified as Dermacentor spp. The suspected diagnosis of ulceroglandular tularemia was confirmed by 1/2560 titer positivity obtained with MAT. Gentamicin (5 mg/kg/day, PO) was initiated for the treatment of both patients, however, LAP did persist in both of them requiring abscess drainage and prolonged treatment with gentamicin following a 14-day course of ciprofloxacin (1500 mg/day, PO). LAP decreased after medical treatment and repetitive drainage procedures. The patients recovered completely without sequela. These cases, to the best of our knowledge, who were the first confirmed tick-borne tularemia cases in our country, were presented to call attention to a different mode of transmission for F.tularensis.
兔热病分布于全球，是由土拉弗朗西斯菌引起的一种人畜共患感染病。土拉弗朗西斯菌可感染多种动物，并能通过多种途径传播给人类，在美国和欧洲，最常见的传播途径是被感染的节肢动物媒介（通常为蜱）叮咬。根据传播途径不同，兔热病的临床表现传统上分为溃疡腺型、腺型、眼腺型、咽型、呼吸型和伤寒型兔热病。节肢动物传播的感染通常导致溃疡腺型兔热病。在土耳其，与饮用受污染水有关的口咽型是兔热病最常见的表现形式。在本报告中，介绍了两例在约兹加特省因蜱叮咬而发生的溃疡腺型兔热病病例。一名33岁女性患者因右腋窝出现压痛性肿块入院。使用阿莫西林克拉维酸进行经验性抗生素治疗未能使疼痛的腋窝肿块有所改善。她报告在出现发热、寒战和局部压痛性肿块之前右肩部被蜱叮咬过。体格检查发现肩部充血，右侧腋窝淋巴结肿大且有压痛。通过微量凝集试验（MAT）血清转化（急性期和恢复期血清效价分别为1/160和1/1280）以及聚合酶链反应检测发现淋巴结抽吸物中土拉弗朗西斯菌DNA呈阳性，从而确诊为疑似溃疡腺型兔热病。根据目标RD1基因扩增结果，病原体被鉴定为土拉弗朗西斯菌全北区亚种。第二例是一名18岁男性，因突发发热、头痛、全身酸痛、呕吐、恶心以及左腋窝压痛性肿块一周病史入院。体格检查发现其头皮有炎性焦痂，左侧颈部淋巴结肿大。患者自己从头皮病变处取下的蜱被鉴定为革蜱属。通过MAT检测获得1/2560效价阳性结果，确诊为疑似溃疡腺型兔热病。对两名患者均开始使用庆大霉素（5mg/kg/天，口服）进行治疗，然而，局部脓肿形成（LAP）在两人身上均持续存在，需要进行脓肿引流，并在环丙沙星（1500mg/天，口服）治疗14天后继续使用庆大霉素进行长时间治疗。经过药物治疗和反复引流操作后，LAP有所减轻。患者完全康复，无后遗症。据我们所知，这些病例是我国首批确诊的蜱传兔热病病例，现予以报告，以引起对土拉弗朗西斯菌不同传播方式的关注。
