The Journal of Radiology Case Reports - interactive Radiology case reports and Radiology review articles

Journal of Radiology Case Reports

Imaging Findings of Ulceroglandular Tularemia

Case Report

Neil Anand1*, Osmani Deochand1, Robyn Murphy1

Radiology Case. 2017 Jan; 11(1):1-6 :: DOI: 10.3941/jrcr.v11i1.2983

Cite this paper

1. Department of Radiology, Morristown Medical Center, Morristown, NJ, USA

Bookmark and Share


         



  ABSTRACT
Top
Abstract
Case Report
Discussion
Teaching Point
Figures
References
Abbreviations
More Images
Your opinion

Francisella tularensis, the causative organism in Tularemia, is a relatively rare disease. There are a few radiological clues to elucidate its presence when suspicion arises. There should be strong consideration for Tularemia in the differential of any patient with its classic symptoms, diffuse cervical lymphadenopathy with evidence of necrosis, and enlarged adenoids. Ultrasound may demonstrate suppurative lymphadenopathy suggestive of infection, as in the case presented. CT often will demonstrate the extent of lymphadenopathy. On chest radiography, tularemia pneumonia is often the presenting finding, which may demonstrate bilateral or lobar infiltrates. Additionally, hilar lymphadenopathy and pleural effusions are often associated findings. Cavitary lesions may be present, which are better delineated on CT scan. We present a case of a 7-year-old male who presented with a painful right-sided palpable neck mass for 9 days, who was diagnosed with Tularemia after numerous admissions.

  CASE REPORT
Top
Abstract
Case Report
Discussion
Teaching Point
Figures
References
Abbreviations
More Images
Your opinion

The authors present a case of a 7-year-old male, with no significant past medical history that presented to the ED with intermittent fever, sore throat, and a painful right-sided palpable neck mass for 9 days. The patient was initially seen in the outpatient setting and was determined to have sore throat with associated adenitis, which was treated with Augmentin ~60mg/kg.

After a 9-day course with poor response, the patient was switched to Cefdinir, during an outpatient visit. Within the following week, the patient continued to have fever up to 102.7o F and an enlarging palpable neck mass, which prompted the mother to bring the patient back to the Emergency Department. Blood work yielded a WBC count of 19,000 (normal 4,500 – 11,000) and CRP of 10 mg/L (normal 0-10mg/L), at which point the patient was admitted and started on IV Clindamycin 13mg/kg/dose q8h.

Workup for CMV, EBV, and Mycoplasma yielded negative results. Ultrasound evaluation [Fig. 1 Preview this figure

Figure 1: Ultrasound
7 year old male patient: Diagnosis of Ulceroglandular Tularemia Findings: A) Real time sonography of the neck soft tissues demonstrate a right neck mass [between red arrows] measuring approximately 3.8 cm x 3.0 cm, corresponding to the area of palpable abnormality. A central area of decreased echogenicity within this nodal mass [asterisk] likely represents necrosis. Overlying subcutaneous edema [double ended yellow arrow] is also present. Numerous other enlarged adjacent lymph nodes were identified on the real-time exam [not displayed]. Findings were found to be consistent with suppurative nodal masses, seen in the setting of Tularemia. B) Color Doppler image of the neck soft tissues demonstrate a right neck mass [between red arrows], corresponding to the area of palpable abnormality. There is no flow within the center of this neck mass. Findings were found to be consistent with suppurative nodal masses, seen in the setting of Tularemia. Technique: Ultrasonography was performed using a linear transducer at 12 MHz. A) B-mode Transabdominal sonogram of the neck soft tissues. B) Power Doppler sonogram of the neck soft tissues. Ultrasonography was performed using a linear transducer at 12 MHz.
a and 1b] demonstrated a hypervascular right neck mass measuring approximately 3.8 cm x 3.0cm, corresponding to the area of palpable abnormality. A central area of decreased echogenicity within this nodal mass likely represented necrosis. Overlying subcutaneous edema was also present. Numerous other enlarged enhancing adjacent lymph nodes were identified. To a similar extent, these findings were demonstrated on the patients soft tissue neck CT [Fig. 2 Preview this figure
Figure 2: Computed Tomography
7 year old male patient: Diagnosis of Ulceroglandular Tularemia Findings: Contrast enhanced coronal CT image of the neck soft tissues, 24 days prior to the ultrasound images, demonstrate multiple enlarged, enhancing, right cervical lymph nodes [red circle]. Findings were found to be consistent with reactive lymphadenopathy, seen in the setting of Tularemia. Suppurative lymphadenopathy is not demonstrated at this time. Technique: mA 300, kvp 100, 2.0 mm slice thickness, with 100ml, Omnipaque 350.
].

Following treatment with IV Clindamycin, the patient was discharged home on PO Ciprofloxacin and Linezolid with the presumed diagnosis of Cat Scratch Disease, despite having a history of a cat bite or scratch. However, the patient was re-admitted to the hospital again, after he was found to have ulceroglandular tularemia after discharge, when the Francisella titers yielded positive results. Upon re-admission, a surgical consultation was obtained to perform an incision and drainage of the complex right neck suppurative lymphadenitis. Following successful incision and drainage the patient was given a PICC line, started on Gentamycin 5mg/kg/day IV q8h, and subsequently discharged.

  DISCUSSION
Top
Abstract
Case Report
Discussion
Teaching Point
Figures
References
Abbreviations
More Images
Your opinion

Etiology & Demographics:
As Tularemia is a relatively rare disease, we know of few radiological clues to elucidate its presence when suspicion arises. In fact, the CDC reports approximately 200 cases per year in the US. These few cases in the literature are thus quite helpful. F. tularensis is a gram-negative coccobacillus, which is responsible for Tularemia. It is found most commonly in North American rabbits and ticks. Transmission may be via inhalation, ingestion, vector associated, or contact with infected tissue. Peak incidence occurs in late spring and early summer, with males and females being equally susceptible to Tularemia. While all ages are equally susceptible to Tularemia; young children and young adults are more likely to participate in activities, which would then make them susceptible to exposure. Risk factors associated with Tularemia involve certain hobbies and/or occupations. These include, but are not limited to: hunting, gardening, landscaping, veterinary medicine, and wildlife work. People living in Arkansas, Missouri, and Oklahoma are at a higher risk due to increased concentration of ticks.

Clinical & Imagining Findings:
In 1990, the journal of Pediatric Radiology published a case of a 3-year-old male with oropharyngeal tularemia [4]. The patient was found to have a normal chest radiograph, though thickening of the retropharyngeal tissues was visualized on x-ray of the lateral cervical territory. A CT scan of the neck with contrast was performed and revealed “enlarged adenoids with inhomogeneous enhancement surrounding areas of low attenuation…retropharyngeal swelling, and moderate bilateral cervical and submandibular adenopathy.” Repeat CT scan of the neck with contrast was performed weeks later and showed multiple areas of low attenuation with rim enhancement within the nodal masses and in the retropharyngeal space. The radiological report goes onto describe “multiloculated masses with low attenuation centers and enhancing septa seen in both posterior cervical nodal chains consistent with abscess formation.” The study ultimately found that there should be strong consideration for Tularemia in the differential in any patient with its classic symptoms, diffuse cervical lymphadenopathy with evidence of necrosis, and enlarged adenoids.

A case report from 2016, in the New England Journal of Medicine, provides insight into an incident of Ulceroglandular Tularemia [1]. The patient was a 58-year old female who presented to the hospital with a skin ulcer on her face, constitutional symptoms, fever, and again, cervical lymphadenopathy. CT of the head and neck was performed and demonstrated diffuse unilateral enlarged lymph nodes. They were localized to the left, lateral to the postauricular, submandibular, cervical chains, and supraclavicular territory. In fact, the left submandibular gland was displaced due to the latter lymphadenopathy. The lymph nodes demonstrated contrast enhancement, hypodensity, and with infiltration of the adjacent fat. It should be noted that chest x-rays are often negative in patients with Tularemia. This was the case in the patient presented (Fig. 3 Preview this figure

Figure 3: Conventional Radiography
7 year old male patient: Diagnosis of Ulceroglandular Tularemia Findings: PA view of the chest demonstrates clear lung fields. Technique: Postero-anterior view of the chest.
).

Radiological analysis of pulmonary tularemia can best be obtained through the seminal case study by Avery and Barnett in 1966 [6]. In it, they evaluated 5 cases from North Carolina Memorial Hospital. Fox hunting and exposure to wild rabbits were among the provided histories from these patients. In case one, chest radiograph showed a uniform left lower lobe infiltrate and evidence of bilateral pleural effusions. Case two’s chest x-ray revealed left hilar infiltration with peribronchial streaking and a left upper lobe density. Case three’s chest radiograph was significant for left pleural thickening and pleural effusion, with questionable left lower lobe parenchymal involvement. The chest x-ray of case four demonstrated bilateral, multiple, soft, irregular nodular densities and pleural effusion. Finally, chest x-ray was obtained of the patient in case five and revealed consolidation localized to the left upper lobe, with visualization of a tiny cavitary lesion measuring 1 cm.

To summarize, ultrasound may demonstrate lymphadenopathy suggestive of infection. These nodes may be suppurative, as in the case presented. CT often will demonstrate the extent of the lymphadenopathy. On chest radiography, tularemia pneumonia is often the presenting finding, which include bilateral or lobar infiltrates, hilar lymphadenopathy, and/or pleural effusions.

Treatment & Prognosis:
General medical therapy is the mainstay of Tularemia treatment, often involving a prolonged antibiotic course. Streptomycin is considered to be the drug of choice. Relapse rates of up to 50% have been reported when using Chloramphenicol and Tetracycline. F. tularensis is naturally resistant to Penicillins and first generation Cephalosporins. Surgical intervention is often not needed, unless ulcerative lesions become superinfected and necessitate incision & drainage.

Tularemia generally has a benign course with a vast majority of patients making a full recovery. It is fatal in approximately 5% of untreated cases and 1% of treated cases.

Differential Diagnoses:
Tularemia should be included in the differential diagnosis for patients with necrotic lymphadenopathy of the neck who may also have lobar infiltrates and hilar lymphadenopathy. These are often nonspecific findings but when noted, should be included as a possible diagnostic consideration. Often, the pulmonary manifestations of Tularemia help differentiate it from the different disease entities in the differential. The main differential considerations for ulceroglandular tularemia include but are not limited to: Lyme disease, lymphogranuloma venereum, mononucleosis, and disseminated mycobacterial disease.

Mononucleosis
Infectious mononucleosis is an infection caused by Epstein-Barr virus, which commonly affects young adults, resulting in fever, sore throat, and enlarged lymph nodes within the neck. Infectious mononucleosis may cause hepatosplenomegaly and splenic rupture, in the setting of trauma. Like Tularemia, patients may demonstrate pronounced cervical lymphadenopathy. As with all infectious etiologies, increased FDG avidity has been described. Diagnosis of this disease entity is based predominantly on clinical history, serology, and clinical presentation; not on imagining findings.

Lyme Disease
Lyme disease is a relative rare disease entity caused by the bacterium Borrelia burgdorferi and is transmitted to humans via a tick-borne vector, much like Tularemia. Often Lyme disease does not have associated imaging findings. Additionally, a joint effusion may be present of the affected joints. On MRI, cranial nerve involvement (most commonly CN7) has been described. Hyperintense lesions within the periventricular white matter and spinal cord have been described on T2WI. FDG PET/CT does not show increased radiotracer uptake. On SPECT imaging, there may be abnormal perfusion defect demonstrated on singular frontal, temporal or parietal lobe.

Lymphogranuloma venereum
Lymphogranuloma venereum is an uncommon sexually transmitted disease caused by Chlamydia trachomatis. Computed tomography may demonstrate colonic narrowing or ulceroglandular lymphadenopathy, most commonly within the inguinal regions. As with all infectious etiologies, increased FDG avidity has been described. Diagnosis of this disease entity is based predominantly on clinical history, serology, and clinical presentation; not on imagining findings.

  TEACHING POINT
Top
Abstract
Case Report
Discussion
Teaching Point
Figures
References
Abbreviations
More Images
Your opinion

There should be strong consideration for Tularemia in the differential in any patient with the classic symptoms, diffuse cervical lymphadenopathy with evidence of necrosis, and enlarged adenoids. Ultrasound and CT may demonstrate suppurative lymphadenopathy suggestive of infection; while chest radiography may demonstrate bilateral or lobar infiltrates.








  FIGURES
Top
Abstract
Case Report
Discussion
Teaching Point
Figures
References
Abbreviations
More Images
Your opinion

Display figure 1 in original size

Figure 1: 7 year old male patient: Diagnosis of Ulceroglandular Tularemia
Findings: A) Real time sonography of the neck soft tissues demonstrate a right neck mass [between red arrows] measuring approximately 3.8 cm x 3.0 cm, corresponding to the area of palpable abnormality. A central area of decreased echogenicity within this nodal mass [asterisk] likely represents necrosis. Overlying subcutaneous edema [double ended yellow arrow] is also present. Numerous other enlarged adjacent lymph nodes were identified on the real-time exam [not displayed]. Findings were found to be consistent with suppurative nodal masses, seen in the setting of Tularemia.
B) Color Doppler image of the neck soft tissues demonstrate a right neck mass [between red arrows], corresponding to the area of palpable abnormality. There is no flow within the center of this neck mass. Findings were found to be consistent with suppurative nodal masses, seen in the setting of Tularemia.
Technique: Ultrasonography was performed using a linear transducer at 12 MHz. A) B-mode Transabdominal sonogram of the neck soft tissues. B) Power Doppler sonogram of the neck soft tissues. Ultrasonography was performed using a linear transducer at 12 MHz.


Figure 1: Ultrasound (Open in original size)
7 year old male patient: Diagnosis of Ulceroglandular Tularemia
Findings: A) Real time sonography of the neck soft tissues demonstrate a right neck mass [between red arrows] measuring approximately 3.8 cm x 3.0 cm, corresponding to the area of palpable abnormality. A central area of decreased echogenicity within this nodal mass [asterisk] likely represents necrosis. Overlying subcutaneous edema [double ended yellow arrow] is also present. Numerous other enlarged adjacent lymph nodes were identified on the real-time exam [not displayed]. Findings were found to be consistent with suppurative nodal masses, seen in the setting of Tularemia.
B) Color Doppler image of the neck soft tissues demonstrate a right neck mass [between red arrows], corresponding to the area of palpable abnormality. There is no flow within the center of this neck mass. Findings were found to be consistent with suppurative nodal masses, seen in the setting of Tularemia.
Technique: Ultrasonography was performed using a linear transducer at 12 MHz. A) B-mode Transabdominal sonogram of the neck soft tissues. B) Power Doppler sonogram of the neck soft tissues. Ultrasonography was performed using a linear transducer at 12 MHz.


Back Back


Display figure 2 in original size
Figure 2: 7 year old male patient: Diagnosis of Ulceroglandular Tularemia
Findings: Contrast enhanced coronal CT image of the neck soft tissues, 24 days prior to the ultrasound images, demonstrate multiple enlarged, enhancing, right cervical lymph nodes [red circle]. Findings were found to be consistent with reactive lymphadenopathy, seen in the setting of Tularemia. Suppurative lymphadenopathy is not demonstrated at this time.
Technique: mA 300, kvp 100, 2.0 mm slice thickness, with 100ml, Omnipaque 350.


Figure 2: Computed Tomography (Open in original size)
7 year old male patient: Diagnosis of Ulceroglandular Tularemia
Findings: Contrast enhanced coronal CT image of the neck soft tissues, 24 days prior to the ultrasound images, demonstrate multiple enlarged, enhancing, right cervical lymph nodes [red circle]. Findings were found to be consistent with reactive lymphadenopathy, seen in the setting of Tularemia. Suppurative lymphadenopathy is not demonstrated at this time.
Technique: mA 300, kvp 100, 2.0 mm slice thickness, with 100ml, Omnipaque 350.


Back Back


Display figure 3 in original size
Figure 3: 7 year old male patient: Diagnosis of Ulceroglandular Tularemia
Findings: PA view of the chest demonstrates clear lung fields.
Technique: Postero-anterior view of the chest.


Figure 3: Conventional Radiography (Open in original size)
7 year old male patient: Diagnosis of Ulceroglandular Tularemia
Findings: PA view of the chest demonstrates clear lung fields.
Technique: Postero-anterior view of the chest.


Back Back


Display figure 4 in original size
Figure 4: Differential Diagnosis table for Ulceroglandular Tularemia.

Figure 4: Table (Open in original size)
Differential Diagnosis table for Ulceroglandular Tularemia.

Back Back


Display figure 5 in original size
Figure 5: Summary table for Ulceroglandular Tularemia.

Figure 5: Table (Open in original size)
Summary table for Ulceroglandular Tularemia.

Back Back


  REFERENCES
Top
Abstract
Case Report
Discussion
Teaching Point
Figures
References
Abbreviations
More Images
Your opinion



1. Baggett M, Gonzalez G, Bhattacharyya R. Case 4-2016. New England Journal of Medicine 2016;374(6):573-581 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

2. Dogan S, Ekinci A. Ultrasonography and contrast-enhanced CT findings of tularemia in the neck. Diagnostic and Interventional Radiology 2016;22(5):430-435 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

3. Treat J, Hess S, McGowan K, Yan A, Kovarik C. Ulceroglandular Tularemia. Pediatric Dermatology 2010;28(3):318-320 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

4. Umlas SJaramillo D. Massive adenopathy in oropharyngeal tularemia; C. T demonstration Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

5. Sjöstedt A. Special Topic on Francisella tularensis and Tularemia. Front Microbio 2011;2 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

6. Avery F, Barnett T. Pulmonary Tularemia: A Report of Five Cases and Consideration of Pathogenesis and Terminology. American Review of Respiratory Disease 1996;95(4), 584-591 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

7. Erdem H, Ozturk-Engin D. Evaluation of tularaemia courses: a multicentre study from Turkey. Clinical Microbiology and Infection 2014;20(12):O1042-O1051 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

8. 1. Mani R, Morton R, Clinkenbeard K. Ecology of Tularemia in Central US Endemic Region Curr Trop Med Rep Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

9. Robson C. Imaging of Granulomatous Lesions of the Neck in Children. Radiologic Clinics of North America 2000;38(5):969-977 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

10. Rubin, Sanford A. Radiographic spectrum of pleuropulmonary tularemia. American Journal of Roentgenology 1978 131:2, 277-281. Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

11. Kim, Eun A., Kyung Soo Lee, Steven L. Primack, Hye Kyung Yoon, Hong Sik Byun, Tae Sung Kim, Gee Young Suh, O. Jung Kwon, and Joungho Han "Viral Pneumonias in Adults: Radiologic and Pathologic Findings." RadioGraphics 22.Suppl_1 (2002): n Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

12. Fu, XS, LM Guo, K. Lv, and L. Wang "Sonographic Appearance of Cervical Lymphadenopathy Due to Infectious Mononucleosis in Children and Young Adults." PubMed.gov Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

13. Gurel, S, Cosgun, Z, Sezgin, S, Gurel, K, A Pictorial Review of MRI Features of Oropharyngeal Tularemia. Radiological Society of North America 2011 Scientific Assembly and Annual Meeting, November 26 - December 2, 2011 ,Chicago IL.archive.rsna.org/2011/11010922.html Accessed November 29, 2016.
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

14. Nieuwenhuis, Rutger F, Ossewaarde, M. Jacobus, Gotz, Hannelore M. “Resurgence of Lymphogranuloma Venereum in Western Europe: An Outbreak of Chlamydia trachomatis Serovar L2 Proctitis in the Netherlands among Men Who Have Sex with Men Clinical Infectious Disease Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

15. Donta, Sam T., Richard B. Noto, and John A. Vento "SPECT Brain Imaging in Chronic Lyme Disease." Clinical Nuclear Medicine 37.9 (2012): n Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

  ABBREVIATIONS
Top
Abstract
Case Report
Discussion
Teaching Point
Figures
References
Abbreviations
More Images
Your opinion

CDC: Center for Disease Control
cm: Centimeters
CMV: Cytomegalovirus
CN: Cranial nerve
CRP: C-reactive protein
CT: Computed Tomography
EBV: Epstein-Barr Virus
ED: Emergency Department
F: Fahrenheit
IV: Intravenous
Kg: Kilogram
kvp: Peak kilovoltage
mA: Milliampere
Mg: Milligram
MHz: Megahertz
mL: Milliliters
MRI: Magnetic Resonance Imaging
N/A: Not Applicable
PET: Positron Emission Tomography
PICC: Peripherally Inserted Central Catheter
PO: Per os
T1WI: T1-Weighted Imaging
T2WI: T2-Weighted Imaging
US: Ultrasound
WBC: White Blood Count




  MORE IMAGES
Top
Abstract
Case Report
Discussion
Teaching Point
Figures
References
Abbreviations
More Images
Your opinion

Find more cases and images for:

Tularemia at Radiolopolis or Radiology Search
Rabbits at Radiolopolis or Radiology Search
Lymphadenopathy at Radiolopolis or Radiology Search
Suppurative at Radiolopolis or Radiology Search
Ulceroglandular at Radiolopolis or Radiology Search
Ultrasound at Radiolopolis or Radiology Search
Computer Tomography at Radiolopolis or Radiology Search
Francisella at Radiolopolis or Radiology Search
Tularensis at Radiolopolis or Radiology Search









  YOUR OPINION
Top
Abstract
Case Report
Discussion
Teaching Point
Figures
References
Abbreviations
More Images
Your opinion

Let us know what you think!












Cite this paper


©2020 Journal of Radiology Case Reports :: www.RadiologyCases.com :: Published by EduRad