Tularemia Associated with Natural Water Sources: Two Case Reports and Review of the Literature

Tularemia is a rare zoonosis that is caused by Francisella tularensis and manifests with masses in the head and neck region. The most common form of tularemia is ulceroglandular form; the other clinical forms of tularemia are glandular, oculoglandular, pharyngeal, typhoidal, and pneumonic. The diagnosis of F. tularensis infection is made by serological, culture, or molecular methods. The epidemiological history should be thoroughly questioned and the necessary investigations should be planned with suspicion of tularemia for patients with lymphadenopathy (LAP) and history of contact with unregulated water sources. Although Trabzon is not an endemic area, we present two sporadic cases of oculoglandular and ulceroglandular tularemia in two brothers aged 59 and 57 years. Treatment with streptomycin for 14 days resulted in clinical improvement. Tularemia outbreaks associated with natural water sources in Turkey between January 1, 2000 and August 1, 2017 were screened and scrutinized using by the keywords "tularemi", "kaynak suyu", "LAP", "water resource", "tularemia", "lymphadenopathy" in PubMed, Google Scholar, and Web of Science. We determined that serologic methods are the most commonly used diagnostic method, the oropharyngeal form was the most common clinical form, and aminoglycosides were the most commonly used treatments, while ciprofloxacin and doxycycline are rarely used. There was no mortality except for one patient and there were not enough data about recurrence. Two cases of tularemia associated with natural water resources have been presented in this report. Even if patients do not come from endemic areas, tularemia should be considered in the differential diagnosis of LAP and targeted therapy should be planned