Clinical Manifestations and Pathology

Tularemia may manifest an extremely variable clinical picture depending upon the site of inoculation and the extent of-its spread. In general, the incubation period averages about 3 days, varying from 1 to 9. The disease begins with headache, chills, vomiting, fever, with generalized aches and pains. An ulcer develops at the site of initial entry, while associated lymph nodes become enlarged and tender. The disease lasts 3 to 4 weeks, with sweating, weight loss, and general debility. Convalescence requires 2 to 3 months.

Several clinical types of the disease have been described:

1. The cutaneous (ulceroglandular) type in which an inflamed papule develops at the site of inoculation, which soon breaks down, leaving a punched-out ulcer. There is painful enlargement of associated lymph nodes, which may last 2 to 3 months. The usual signs of infection, fever, and prostration are common.

2. The ophthalmic (oculoglandular) type, which occurs when the bacterium enters via the conjunctival sac. Local inflammation occurs with enlargement of the lymph nodes of the neck. Permanent impairment of vision may occur.

3. The pleuropulmonary type, which develops secondary to the other forms. Milder forms resemble atypical pneumonia and may include shortness of breath, malaise, chills, and pleuritic pain.

4. The gastrointestinal (oropharyngeal) form that is contracted from the ingestion of contaminated food and water and may be accompanied by acute abdominal symptoms such as pain, vomiting, and diarrhea with ulcerative lesions in the intestinal mucosa.

5. The glandular form, which develops without a primary lesion but with enlargement of regional lymph nodes.

6. The typhoidal (septicemic) form that also develops without a primary lesion and without enlarge ment of the regional nodes. Infection arises via the respiratory route or is the late result of local infection.

7. The meningitic type, which is rare in North America but not infrequent in Asia, under certain conditions of insect transmission.

In all these types, subclinical infections may be more common than previously supposed. A recent study in Sweden showed that about 23 percent of the population had been infected, but 32 percent of these were subclinical cases.

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