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Distribution of regions from which tularemia outbreaks were reported in Turkey. area, province A (Zonguldak); area, province B (Bartın); area, province C (Kastamonu). areas show provinces tularemia outbreak emerged in the last 25 years and areas show tularemia epidemics before 1954.
Source publication
An outbreak of tularemia occurred in three provinces in Turkey in February 2004 and reemerged in the same provinces in February 2005. A total of 61 cases, 54 of which were confirmed with the micro-agglutination test, were diagnosed with oropharyngeal tularemia. No culture for Francisella tularensis was attempted, but PCR for F. tularensis was posit...
Contexts in source publication
Context 1
... female patients were admitted to our university hospital in the last week of March 2004 with the same complaints: a cervical mass following fever and pharyngitis that did not respond to antibiotics such as penicillin or cephalosporin. Each patient was from a different province (province A, Zonguldak; province B, Bartın; and province C, Kastamonu), with distances of nearly 50 km between them ( Figure 1). The onset of the symptoms was in February 2004. ...
Context 2
... the following years, tularemia epidemics and sporadic cases were reported at different sites in Anatolia (12,15-23). The tularemia-affected areas of the last 25 years have commonly been located in the Black Sea and Marmara regions of Turkey (Figure 1). This is the first report of tularemia epidemics affecting these three provinces of Turkey. ...
Similar publications
We present here the first five human cases with tularemia from two regions in South Bulgaria in which there had been no previous report of the infection. The cases occurred over a period of 8 months (December 2014 - August 2015). They were treated at the Department of Infectious Diseases in Stara Zagora University Hospital, Bulgaria. We present the...
Citations
... The disease continues to be endemic in parts of North America, Europe and Asia [3]. It has also caused epidemics in different regions in different years in our country, and it can still be seen as sporadic cases from time to time or as regional epidemics [4][5][6]. It was most common in our country (Turkey) in 2011, and the number of cases was reported as 2,151. ...
... Although the most common form of tularemia in the world is the ulceroglandular form, the oropharyngeal form is the most common in our country. It is thought that this situation stems from the fact that the most common way of transmission in our country is through water sources [3][4][5][6]. In our study, the oropharyngeal form which is the most common form (81.25%) was detected, which is in line with the data of our country. ...
... Aminoglycosides are used as the first-line therapy in the treatment of the disease, and doxycycline and quinolones are used as alternatives [3]. In the literature, it has been seen that streptomycin is used most frequently as monotherapy or in combination with doxycycline or quinolones [4,5,10,14]. In our study, it was determined that moxifloxacin was used most frequently. ...
Introduction:
Tularemia is a zoonotic disease caused by Francisella tularensis, a gram-negative, facultative, intracellular coccobacillus. It can occur in different clinical forms, and the most common form in our country (Turkey) is the oropharyngeal form. Unfortunately, the diagnosis of lymphadenitis caused by tularemia is delayed unless it is suspected, especially in sporadic cases. Our aim is to remind clinicians to have tularemia among differentials of lymphadenitis.
Methods:
In this study, the clinical and laboratory findings of 16 tularemia patients between 2011 and 2021 were evaluated retrospectively.
Results:
The mean age of the 16 patients included in the study was 39 years, and 62.5% were female. The patients were diagnosed with tularemia on the average 31st day of their complaints. The rate of use of beta-lactam group antibiotics before diagnosis was 74%. About 81.25% of the patients were engaged in animal husbandry/farming, and living in rural areas (93.75%) and farming (81.25%) were the most common possible risk factors. The patients were admitted to the hospital with the most common complaints of enlarged lymph nodes (100%), fatigue (62.5%) and loss of appetite (56.25%). All patients had lymphadenopathy, and the most common location of lymphadenopathy was the cervical region (81.25%). Moxifloxacin (56.25%) was used most frequently in the treatment of tularemia, and surgical drainage was performed for 31% of the patients.
Conclusion:
The diagnosis of tularemia is often delayed unless clinical suspicion is high. Delayed diagnosis may lead to unnecessary frequent use of antibiotics, especially beta-lactam group antibiotics. As the diagnosis is delayed, since lymph node suppuration is common, surgical intervention may be required. This situation can cause extra burden for both patients and the health system. It may be beneficial to organize trainings to increase awareness among physicians and society in order to make the diagnosis early.
... In a study evaluating 205 cases in Turkey, the complication rate was 40% in cases in which the time from symptom onset to diagnosis was more than 21 days [27]. Researchers have emphasized that treatment success does not depend on ineffective antibiotics and the antibiotic itself, but that the timing of treatment initiation is important [27,36,37]. ...
Background
In this study, we presented two cases of late diagnosed complicated oculoglandular tularemia and reviewed the clinical features of oculoglandular tularemia in cases reported in the last ten years.
Method
Tularemia was diagnosed when serum microagglutination test (MAT) was ≥ 1/160 titer or when there was at least a four-fold increase in MAT titers measured over a two-week interval. We searched the oculoglandular tularemia cases reported in the last 10 years in the PubMed and Google Academic engines.
Results
Case 1 (19 M) and case 2 (15 M) had complaints of fever and burning in the eye. In both cases, the diagnosis of tularemia was delayed. Lymph node suppuration developed in both cases. A total of 19 cases of tularemia were found within the search. In the cases of oculoglandular tularemia reported in the last 10 years, submandibular and preauricular lymphadenopathy were most common after ocular findings and fever. The mean time to diagnosis was 41 ± 94 days, and the complication rate was 31.5%.
Conclusion
Tularemia should definitely be considered in cases of fever and ocular findings, especially in endemic areas. In non-endemic areas, a good anamnesis and clinical suspicion can help diagnose the disease early and reduce the complication rate.
... Dünya' da ülseroglandüler tip sıklıkla görülmektedir. Türkiye' de ise orofarengeal tip sıktır (4,5). Mikroorganizmanın alınmasından 3-5 gün sonra ateş, boyunda lenfadenopati, farenjit, halsizlik gibi nonspesifik şikayetler görülmektedir (4). ...
ÖZET Tularemi, Gram negatif, küçük, kokobasil olan Francisella tularensis tarafından oluşan, granülömatoz, zoonotik bir infeksiyon hastalığıdır. Tularemi dünya üzerinde geniş bir dağılım göstermektedir. Türkiye’de birçok bölgede endemik ve sporadik olarak bulunmaktadır. Konya ve çevresi de endemik olarak bulunabildiği bölgeler arasındadır. Türkiye’de ateş, servikal lenfadenitle başvuran beta laktamaz ürettiği için beta laktam antibiyotiklere yanıt vermeyen hastalarda ayırıcı tanıda tularemi akla gelmelidir. Bu yazıda, 28 yaşında akut tonsillit, servikal lenfadeniti olan, nonspesifik antibiyotiklere yanıtı olmayan tavşan eti tüketimi sonrası şikayetleri başlayan orofarengeal tipte tularemi olgusu sunulmaktadır. Anahtar Kelimeler: Francisella tularensis, tularemi, tavşan
... Francisella tularensis is a pathogen that causes severe lethal infections in humans and some mammals. Studies have shown that successful antibiotic therapy for tularemia depends on timely diagnosis [21] . Because of this, an early and reliable diagnosis of the disease is essential. ...
Tularemia is a highly contagious zoonotic infection caused by Francisella tularensis. Bacterial culture, serology and molecular
methods are used in the diagnosis of tularemia. Th e agent is a dangerous pathogen, and the importance of serological tests in diagnosis has
increased because of the difficulty in culturing them. In this study, a practical, fast and reliable lateral fl ow-based immunochromatographic
test was planned to detect F. tularensis specific antibodies in the field. Partially purified lipopolysaccharide antigen obtained from the live
vaccine strain of F. tularensis was used as antigen. To determine the sensitivity of the test, 17 true positive tularemia serum samples with
known Microagglutination test results, and to determine of specificity of the test, used 30 true negative serum samples. In this study also
tested Brucella-positive patient sera of various titers from our laboratory"s serum bank to determine possible cross-reactivity with Brucella
antibodies. Th e sensitivity and specificity of the Lateral Flow Test (LFT) rapid diagnostic kit were evaluated in comparison to the standard
microagglutination test. Th e sensitivity and specificity of the newly developed Lateral Flow Test (LFT) were found at 100% and 93.5%,
respectively. Th e tests revealed any possible cross-reaction with positive sera for brucellosis in lateral fl ow test for tularemia and showed
5% cross-reaction with this disease. Cross-reactions were observed at antibody titers of 1:20 and below. In conclusion, it was concluded
that the newly developed lateral fl ow test is a fast, reliable, and practical alternative test for the serological diagnosis of tularemia and crossreaction
in the serological tests conducted for brucellosis and tularemia should always be considered.
... The sources of infection were not fully elucidated but had been likely associated with drinking of water contaminated by excrements and urine. Two older studies from Turkey reported 130 cases of tularaemia, where only two cases described the disease in children below 10 years of age (Celebi et al., 2006(Celebi et al., , 2008. Another study described an outbreak in Oulu region of Finland during the summer of 2007, where a total of 50 children were infected and 31 of these were younger than 4 years of age. ...
Although Francisella (F.) tularensis is a well-described and understood zoonotic pathogen, its importance in Central Europe is relatively minor and, as such, tularaemia may be missed in the differential diagnosis. The annual incidence of tularaemia in the Czech Republic is relatively stable with up to 100 reported cases per year, except in the epidemic years 1998 and 1999 with 225 and 222 reported cases, respectively. It is, however, higher in comparison with the neighbouring countries. The common route of transmission in Central Europe is handling infected animals. Tularaemia is not commonly recognized as a tick-borne disease. Here we report two rare cases of a tick bite-associated ulceroglandular form of tularaemia in 2.5-year-old and 6.5-year-old children presenting with cervical lymphadenopathy. The unusual and interesting features of those cases are the young age and relatively uncommon route of transmission suggesting possible changes in the epidemiology of tularaemia in the Czech Republic. Therefore, the infection with F. tularensis should be considered in the differential diagnosis after a tick bite even in infants.
... Further studies are needed in order to determine if LPS is detectable in additional matrices such as urine, lymph node biopsies and abscesses, the latter of which are commonly reported to have high bacterial burden. Analysis of lymph node biopsies or aspirates is a common technique for confirming F. tularensis infection [48,49]. In addition to exploring presence of LPS in clinical samples, we would like to examine how LPS is shed/secreted over the course of F. tularensis infection in order to characterize how this biomarker can be most efficiently detected. ...
Francisella tularensis is the causative agent of tularemia, a zoonotic bacterial infection that is often fatal if not diagnosed and treated promptly. Natural infection in humans is relatively rare, yet persistence in animal reservoirs, arthropod vectors, and water sources combined with a low level of clinical recognition make tularemia a serious potential threat to public health in endemic areas. F. tularensis has also garnered attention as a potential bioterror threat, as widespread dissemination could have devastating consequences on a population. A low infectious dose combined with a wide range of symptoms and a short incubation period makes timely diagnosis of tularemia difficult. Current diagnostic techniques include bacterial culture of patient samples, PCR and serological assays; however, these techniques are time consuming and require technical expertise that may not be available at the point of care. In the event of an outbreak or exposure a more efficient diagnostic platform is needed. The lipopolysaccharide (LPS) component of the bacterial outer leaflet has been identified previously by our group as a potential diagnostic target. For this study, a library of ten monoclonal antibodies specific to F. tularensis LPS were produced and confirmed to be reactive with LPS from type A and type B strains. Antibody pairs were tested in an antigen-capture enzyme-linked immunosorbent assay (ELISA) and lateral flow immunoassay format to select the most sensitive pairings. The antigen-capture ELISA was then used to detect and quantify LPS in serum samples from tularemia patients for the first time to determine the viability of this molecule as a diagnostic target. In parallel, prototype lateral flow immunoassays were developed, and reactivity was assessed, demonstrating the potential utility of this assay as a rapid point-of-care test for diagnosis of tularemia.
... Since 1988, tularemia has reemerged in Turkey, with recurring outbreaks [2][3][4][5][6][7]. The majority of outbreaks occurred in the 2000s in the northern and northwestern parts of Turkey [4,6,[8][9][10][11][12]. Numerous cases and outbreaks have occurred since 2009, particularly in the central part of Turkey, and tularemia has spread across a large part of the country since then [2,7,[13][14][15][16]. ...
... In 2004, it was added to the list of notifiable diseases by the Turkish Ministry of Health ( Figure 1). A few case reports of tick-borne and probable contaminated food-related familial tularemia have been seen in Turkey [17][18][19]; however, the main clinical form of tularemia in Turkey is oropharyngeal, and numerous waterborne tularemia outbreaks have been reported in the last few decades [8][9][10][11][12][13][14][15][16]. ...
... Additionally, heavy precipitation and floods are shown to be primary factors of drinking-water contamination [29][30]. Heavy precipitation before an outbreak was previously reported in some studies in Turkey [3,6,8,9,23]. Additionally, turbid and dirty tap water was reported before outbreaks without documented flooding [3,8,27]. Turkey saw 62 reports of heavy precipitation and flooding in 2007 and 42 in 2008, but 128 in 2009 and 156 in 2010 [31], with a considerable increase in the number of tularemia cases in the latter period (Figure 1). ...
Introduction:
Tularemia has reemerged and spread throughout Turkey, and the number of cases has increased. In this study, we report on a waterborne outbreak of tularemia in the spring of 2013 in a region which was previously disease-free, and we investigated the reasons for the outbreak.
Methodology:
The index case, a 17-year-old male, was diagnosed with oropharyngeal tularemia. An outbreak investigation was initiated after receiving information from other patients with similar symptoms from the same village along with Balkıca, Tavas, and Denizli. An epidemiological and environmental investigation was conducted. Tonsil swab specimens/lymph node aspirates collected from patients, and water samples collected from unchlorinated drinking water sources, were cultured. Additionally, a real-time polymerase chain reaction (RT-PCR) was performed on these samples. Serum samples from patients were analyzed for antibody response.
Results:
A total of 7 patients were found in this outbreak investigation. The attack rate was found to be 1% among the people of the village and 25% among patients' family members. The drinking-water system was contaminated with F. tularensis during this outbreak.
Conclusions:
Lack of appropriate water infrastructure and sanitation was the primary reason for this tularemia outbreak in Turkey. Improving the water source infrastructure and sanitation should be the primary approach to preventing tularemia outbreaks.
... Since 1988, tularemia has reemerged in Turkey, with recurring outbreaks [2][3][4][5][6][7]. The majority of outbreaks occurred in the 2000s in the northern and northwestern parts of Turkey [4,6,[8][9][10][11][12]. Numerous cases and outbreaks have occurred since 2009, particularly in the central part of Turkey, and tularemia has spread across a large part of the country since then [2,7,[13][14][15][16]. ...
... In 2004, it was added to the list of notifiable diseases by the Turkish Ministry of Health ( Figure 1). A few case reports of tick-borne and probable contaminated food-related familial tularemia have been seen in Turkey [17][18][19]; however, the main clinical form of tularemia in Turkey is oropharyngeal, and numerous waterborne tularemia outbreaks have been reported in the last few decades [8][9][10][11][12][13][14][15][16]. ...
... Additionally, heavy precipitation and floods are shown to be primary factors of drinking-water contamination [29][30]. Heavy precipitation before an outbreak was previously reported in some studies in Turkey [3,6,8,9,23]. Additionally, turbid and dirty tap water was reported before outbreaks without documented flooding [3,8,27]. Turkey saw 62 reports of heavy precipitation and flooding in 2007 and 42 in 2008, but 128 in 2009 and 156 in 2010 [31], with a considerable increase in the number of tularemia cases in the latter period (Figure 1). ...
Introduction: Tularemia has reemerged and spread throughout Turkey, and the number of cases has increased. In this study, we report on a waterborne outbreak of tularemia in the spring of 2013 in a region which was previously disease-free, and we investigated the reasons for the outbreak.
Methodology: The index case, a 17-year-old male, was diagnosed with oropharyngeal tularemia. An outbreak investigation was initiated after receiving information from other patients with similar symptoms from the same village along with Balkıca, Tavas, and Denizli. An epidemiological and environmental investigation was conducted. Tonsil swab specimens/lymph node aspirates collected from patients, and water samples collected from unchlorinated drinking water sources, were cultured. Additionally, a real-time polymerase chain reaction (RT-PCR) was performed on these samples. Serum samples from patients were analyzed for antibody response.
Results: A total of 7 patients were found in this outbreak investigation. The attack rate was found to be 1% among the people of the village and 25% among patients' family members. The drinking-water system was contaminated with F. tularensis during this outbreak.
Conclusions: Lack of appropriate water infrastructure and sanitation was the primary reason for this tularemia outbreak in Turkey. Improving the water source infrastructure and sanitation should be the primary approach to preventing tularemia outbreaks.
... Ülkemizde tularemi ilk kez 1936 yılında tespit edilmiş olup günümüze kadar birçok tularemi salgını bildirilmiştir 1,14,15 . Ülkemizde son yıllarda laboratuvar tanı imkanlarının gelişmesi sonucu klinik ve çevresel örneklerden F.tularensis'in izolasyonuna ve moleküler yöntemlerle tespitine yönelik çalışmalar yapılmıştır. ...
Francisella tularensis is a gram-negative, coccobasillus, facultative intracellular bacteria and causes a zoonotic disease, tularemia in humans. F.tularensis has four subspecies, which have different virulences for humans as F.tularensis subsp. tularensis, F.tularensis subsp. holarctica, F.tularensis subsp. mediasiatica and F.tularensis subsp. novicida. F.tularensis subsp. tularensis is the most virulent subspecies and mortality rate is high in human cases. F.tularensis subsp. holarctica, which has been reported in our country to date, has lower virulence than that of subsp. tularensis, and causes rare lethality among untreated patients. According to the erythromycin resistance and the properties of glucose-glycerol fermentation, F.tularensis subsp. holarctica has three biovar as biovar I, biovar II and biovar japonica. F.tularensis subsp. mediasiatica has been reported only in a few central asian countries and its virulence is similar to the F.tularensis subsp. holarctica F.tularensis subsp. novicida is avirulent for immunocompetent individuals but has been observed to cause infection in immunocompromised individuals. The aim of this study was to determine the F.tularensis subspecies in 259 F.tularensis strains isolated from clinical specimens, drinking water and a rodent sample and 517 F.tularensis PCR-positive DNA isolated from clinical specimens between years 2009 and 2014. Conventional PCR was performed using primers specific for the RD1 (Region Difference) region of F.tularensis. Subspecies were differentiated depending on the difference in PCR amplification product size. In our study, F.tularensis subsp. holarctica was detected in 764 samples yielding 922 base pair (bp) amplification product. The DNA samples obtained from one water and 11 lymph aspirates were determined as F.tularensis subsp. holarctica biovar japonica. The DNA sequence analysis of the amplification product of the RD1 region of the isolate from water sample was determined. The 1136 bp nucleotide sequence obtained from the DNA sequence analysis was 100% similar to F.tularensis subsp. holarctica biovar japonica (FCS075 strain-accesion number AF469618) when compared with GenBank data. The whole genome sequence of this isolate was also determined and recorded to GenBank with accesion number CP007148. None of the samples used in our study belonged to other sub-species. F.tularensis subsp. holarctica biovar japonica positive 11 lymph aspirate samples were sent to our center from Ankara (n= 1), Kayseri (n= 1) and Afyon (n= 9) provinces. The results of the current study revealed that F.tularensis subsp. holarctica biovar japonica caused a tularemia outbreak in a village in Afyon province at first time and it was observed sporadically in two other different provinces.
... In most case reports, even asymptomatic patients are treated with a full course of antibiotics because of the fear of a relapse [46], as we did in two pulmonary cases. However, there are reports of good outcomes without treatment in asymptomatic patients [41,47]. In our daily practice, we have never seen a relapse of tularemia in patients with assumed, previously healed tularemia without antibiotic treatment or in patients with tularemia after established immunosuppression, which could be a clue for latent infection as in other intracellular infections. ...
Background
Tularemia, a zoonotic disease caused by Francisella tularensis, can cause a broad spectrum of disease in humans including six major clinical presentations: the ulceroglandular, glandular, oculoglandular, oropharyngeal, typhoidal and pneumonic form. The epidemiology and ecology and thus transmission of tularemia are complex, depending on conditions unique to specific locations.
Case series and methods
Thirteen cases with different forms of the disease and one very rare case of a myocarditis are reported, discussed, and reviewed within the scope of current literature.
Conclusion
Tularemia is a rare, but emerging disease in Central Europe with glandular and ulceroglandular disease as its predominant forms. Transmission is mainly caused by contact with lagomorphs, rodents and tick bites. However, domestic cats may play an important role in transmission too. Myocarditis is probably a worldwide, but very rare manifestation of tularemia.
