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Tularemia, caused by the bacterium Francisella tularensis, has various clinical manifestations related to the route of introduction. People can become infected in several ways, including tick and deer fly bites, skin contact with infected animals and their carcasses, eating insufficiently cooked contaminated meat, drinking contaminated water, inhaling contaminated aerosols or agricultural and landscaping dust, and bioterrorism. The incubation period is usually 3‐5 days, but can range from 1 to 14 days.

All forms of tularemia result in a sudden onset of non‐specific influenza‐like symptoms, including high fever, cough, sore throat, chills, headache, and generalized body aches. Sometimes, nausea, vomiting, and diarrhea may also occur. All forms may lead to sepsis, pneumonia, and meningitis. The clinical forms include ulceroglandular, glandular, oculoglandular septic, oropharyngeal, and pneumonic [53].

Ulceroglandular tularemia is the most common form. It begins at the skin site of the bite of a tick or fly. A papule appears that becomes pustular, later ulcerates, and finally develops into an eschar. Regional lymph nodes become swollen, painful, and tender and rarely suppurate and discharge purulent material. Glandular tularemia has no skin involvement, only regional lymphadenopathy similar to ulceroglandular disease. Oculoglandular tularemia is caused by the bacillus entering the eye. Conjunctival ulceration occurs followed by regional lymphadenopathy of the cervical and pre‐auricular nodes. Septic tularemia begins with non‐specific symptoms of fever, nausea, vomiting, and abdominal pain, eventually leading to confusion, coma, multisystem organ failure, and septic shock.

Oropharyngeal tularemia is caused by consumption of contaminated water or food, leading to exudative pharyngitis, which may be accompanied by oral ulceration. Abdominal pain, diarrhea, and vomiting may accompany this type. Regional lymphadenopathy occurs, affecting the cervical and retropharyngeal nodes.

Pneumonic tularemia may be caused by lung exposure to an infective aerosol from soil, grain, or hay. An infective aerosol can also result from a bioterrorist attack. The clinical presentation may be cough, pleuritic pain, and rarely dyspnea. Despite the lungs being the primary route of entry, it is not uncommon for tularemic pneumonia to present as non‐specific systemic signs without respiratory symptoms, and often a normal chest x‐ray.

There is no documented person‐person transmission of tularemia. Routine precautions are adequate when transporting and caring for patients. The vehicle and equipment, however, must be thoroughly cleaned and decontaminated after patient transport. Antibiotics such as streptomycin or gentamycin are effective, and antibiotics for treating patients infected with tularemia in a bioterrorist event are included in the national pharmaceutical stockpile maintained by the CDC.