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Tularemia presenting as a unilateral pleural effusion in a metropolitan city
Respiratory Medicine CME 3 (2010) 195–197
Contents lists available at ScienceDirect
Respiratory Medicine CME journal homepage: www.elsevier.com/locate/rmedc
Case Report
Tularemia presenting as a unilateral pleural effusion in a metropolitan city Kurugundla Navatha*, Wei Li 1, Chukuma Okadigwe 2, Tom Russi 3, Rocco Franco 4 New York Methodist Hospital, 506, 6th street, Brooklyn, NY, USA
a r t i c l e i n f o
a b s t r a c t
Article history: Received 5 June 2009 Accepted 16 July 2009
We report a young patient who went on a camping trip to a local park in a metropolitan area complaining of chest pain. On further investigations, he was found to have left sided pleural effusion. Thoracentesis revealed alkaline PH and the fluid was an exudate. The culture grew Francisella tularensis. The patient was treated with streptomycin with marked clinical improvement. Ó 2009 Elsevier Ltd. All rights reserved.
Keywords: Tularemia Francisella tularensis Exudate
1. Case report A twenty seven year old teacher went on a camping trip with his students to a local park in Brooklyn, New York, which used to be a metropolitan airport. Two weeks later, the patient presented to the hospital complaining of left sided chest pain. The pain worsened with inspiration and was associated with an occasional dry cough, sweating and subjective fever. The patient also reported chest wall and head trauma two weeks ago while playing basketball. He also complained of headache, dizziness and parasthesias in hands. No motor or cranial nerve abnormalities were present. His past medical history was significant for Herpes Simplex virus type I and attention deficit hyperactivity disorder. He is an active smoker. Upon admission, his physical examination was notable for tachycardia and tachypnea with an oxygen saturation of 99% on room air. He was thin built and tall (60 200 ) and not in any respiratory distress. Lung examination revealed dullness at the left base with decreased breath sounds. Chest X ray and computed tomography of the chest revealed left sided pleural effusion (Figs. 1 and 2a and b). Ultrasound guided thoracentesis was performed to rule out hemothorax. About 1.2 l of clear straw colored fluid were removed and thin fibrous strands were visualized by ultrasound. He was started on broad spectrum antibiotics. HIV, Hepatitis panel, mycoplasma, syphilis testing were negative. * Corresponding author. Tel.: þ1 718 780 5835; fax: þ1 718 780 5836. E-mail addresses: [email protected] (K. Navatha), [email protected] (W. Li), [email protected] (C. Okadigwe), [email protected] (T. Russi), butiki3@ hotmail.com (R. Franco). 1 Tel.: þ1 718 780 3390. 2 Tel.: þ1 718 287 0505. 3 Tel.: þ1 718 238 4279. 4 Tel.: þ1 718 372 0500. 1755-0017/$36.00 Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.rmedc.2009.07.005
Pleural fluid analysis revealed a PH of 8, glucose of 90 and very high LDH of 2007 with total protein of 4. Serum LDH was 439 and serum total protein was 5.5. The fluid was consistent with a complicated parapneumonic exudative effusion. WBC was 820 and the differential was 46% neutrophils, 43% lymphocytes and 11% monocytes/macrophages. Pleural fluid cytology was negative for malignancy. Pleural fluid gram stain was negative, but the culture grew gram negative organisms (Fig. 3). The patient had a left sided video assisted thoracoscopic surgery with decortication as he remained febrile despite broad spectrum antibiotics. Follow-up imaging studies showed recurrent pleural effusion with persistent atelectasis. Intra-operatively, 300 ml of serous straw colored pleural fluid were removed and strands of adhesive fibrinous tissue were identified. Tan fibrinous pleural peel was seen trapping the left lower lobe. Pathology of pleural tissue demonstrated fibroconnective tissue with acute and chronic inflammation and extensive necrosis. Francisella tularensis was ultimately identified from the pleural fluid culture by polymerase chain reaction and direct fluorescent antibody testing. He was treated with streptomycin, clinically improved and discharged home. 2. Discussion The earliest description of tularemia was in Japan in the year 1837. It is caused by the gram-negative coccobacillus, Francisella tularensis and has various names such as ‘‘rabbit fever’’, ‘‘deer-fly fever’’, ‘‘Ohara fever’’ and ‘‘Francis disease’’. The primary vectors are ticks and deer flies. However, it can also be spread through other arthropods. The incidence rate is less than 1 per 100,000. Person to person transmission has not been reported, consequently there is no role for isolation. It can be spread by
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K. Navatha et al. / Respiratory Medicine CME 3 (2010) 195–197
Fig. 1. Chest X-ray showing left sided pleural effusion.
inoculation of the skin or mucous membranes with blood or tissue while handling infected animals (1). It can also be transmitted by contact with fluids from infected flies or ticks, bites of infected ticks, or handling or eating insufficiently cooked rabbits. Finally, drinking contaminated water or breathing dust that has been contaminated with this bacterium is another source of transmission. Tularemia has six characteristic presentations. The ulceroglandular form is the most common type representing 75% of all presentations. The glandular, oropharyngeal, pneumonic, oculoglandular, and typhoidal forms are other manifestations of tularemia(2). The pneumonic form as was diagnosed in our patient, is spread by inhalation of aerosolized Francisella tularensis or by secondary infection from another form of tularemia. They can present with sore throat, swelling of the lymph nodes in the lungs, abrupt onset of fever, chills, headache, muscle aches, joint pains, dry cough, and progressive weakness. Tularemic pneumonia is usually complicated by pleural involvement resulting in effusions. Pleurisy and pleural effusion without pneumonia can occur and is an uncommon presentation of tularemia. The incidence of pleural effusion increases with the duration of the disease and is often bilateral. It is usually a turbid or serosanguinous exudative effusion
Fig. 2. (a) Computed tomography of the chest showing consolidation in the left lower lobe with air bronchograms and pleural effusion. (b) Computed tomography of the chest mediastinal view showing left sided pleural effusion.
with high protein values and a predominance of either lymphocytes or neutrophils (3). However, unlike typical parapneumonic effusions, the pleural fluid glucose and pH levels are not low. Pleuropulmonary tularemia causes diagnostic difficulties and may be confused with tuberculous pleurisy. Like tuberculous effusion, tularemia effusions can be T-lymphocyte rich with high adenosine deaminase(ADA), lysozyme(LZM) and B2 microglobulin concentration(4). Nonetheless, a definitive diagnosis of tularemia is made by culture(5).
3. Conclusion Tularemia should be considered in the differential diagnosis in a patient presenting with exudative pleural effusion with extremely high LDH and alkaline PH. A careful history taking of recent travel or camping must be obtained. It remains unclear if our patient acquired tularemia either by aerosolization or by an arthropod vector bite. Conflict of interest Fig. 3. Gram negative coccobacillus.
Neither author has any conflict of interest.
K. Navatha et al. / Respiratory Medicine CME 3 (2010) 195–197
References 1. Craven RR, Hall JD, Fuller JR, Taft-Benz S, Kawula TH, et al. Francisella tularensis invasion of lung epithelial cells. Infect Immun 2008 Jul;76(7):2833–42. Epub 2008 Apr 21. 2. Hepburn MJ, Simpson AJ. Tularemia: current diagnosis and treatment options. Expert Rev Anti Infect Ther 2008 Apr;6(2):231–40.
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3. Funk LM, Simpson SQ, Mertz G, Boyd J. Tularemia presenting as an isolated pleural effusion. West J Med 1992 Apr;156(4):415–7. 4. Pettersson T, Nyberg P, Nordstrom D, Riska H. Similar pleural fluid findings in pleuropulmonary tularemia and tuberculous pleurisy. Chest 1996;109:572–5. 5. Dennis DT, Inglesby TV, Henderson DA, Bartlett JG, Ascher MS, Eitzen E, et al. Tularemia as a biological weapon: medical and public health management. JAMA 2001 Jun 6;285(21):2763–73.
Contents lists available at ScienceDirect
Respiratory Medicine CME journal homepage: www.elsevier.com/locate/rmedc
Case Report
Tularemia presenting as a unilateral pleural effusion in a metropolitan city Kurugundla Navatha*, Wei Li 1, Chukuma Okadigwe 2, Tom Russi 3, Rocco Franco 4 New York Methodist Hospital, 506, 6th street, Brooklyn, NY, USA
a r t i c l e i n f o
a b s t r a c t
Article history: Received 5 June 2009 Accepted 16 July 2009
We report a young patient who went on a camping trip to a local park in a metropolitan area complaining of chest pain. On further investigations, he was found to have left sided pleural effusion. Thoracentesis revealed alkaline PH and the fluid was an exudate. The culture grew Francisella tularensis. The patient was treated with streptomycin with marked clinical improvement. Ó 2009 Elsevier Ltd. All rights reserved.
Keywords: Tularemia Francisella tularensis Exudate
1. Case report A twenty seven year old teacher went on a camping trip with his students to a local park in Brooklyn, New York, which used to be a metropolitan airport. Two weeks later, the patient presented to the hospital complaining of left sided chest pain. The pain worsened with inspiration and was associated with an occasional dry cough, sweating and subjective fever. The patient also reported chest wall and head trauma two weeks ago while playing basketball. He also complained of headache, dizziness and parasthesias in hands. No motor or cranial nerve abnormalities were present. His past medical history was significant for Herpes Simplex virus type I and attention deficit hyperactivity disorder. He is an active smoker. Upon admission, his physical examination was notable for tachycardia and tachypnea with an oxygen saturation of 99% on room air. He was thin built and tall (60 200 ) and not in any respiratory distress. Lung examination revealed dullness at the left base with decreased breath sounds. Chest X ray and computed tomography of the chest revealed left sided pleural effusion (Figs. 1 and 2a and b). Ultrasound guided thoracentesis was performed to rule out hemothorax. About 1.2 l of clear straw colored fluid were removed and thin fibrous strands were visualized by ultrasound. He was started on broad spectrum antibiotics. HIV, Hepatitis panel, mycoplasma, syphilis testing were negative. * Corresponding author. Tel.: þ1 718 780 5835; fax: þ1 718 780 5836. E-mail addresses: [email protected] (K. Navatha), [email protected] (W. Li), [email protected] (C. Okadigwe), [email protected] (T. Russi), butiki3@ hotmail.com (R. Franco). 1 Tel.: þ1 718 780 3390. 2 Tel.: þ1 718 287 0505. 3 Tel.: þ1 718 238 4279. 4 Tel.: þ1 718 372 0500. 1755-0017/$36.00 Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.rmedc.2009.07.005
Pleural fluid analysis revealed a PH of 8, glucose of 90 and very high LDH of 2007 with total protein of 4. Serum LDH was 439 and serum total protein was 5.5. The fluid was consistent with a complicated parapneumonic exudative effusion. WBC was 820 and the differential was 46% neutrophils, 43% lymphocytes and 11% monocytes/macrophages. Pleural fluid cytology was negative for malignancy. Pleural fluid gram stain was negative, but the culture grew gram negative organisms (Fig. 3). The patient had a left sided video assisted thoracoscopic surgery with decortication as he remained febrile despite broad spectrum antibiotics. Follow-up imaging studies showed recurrent pleural effusion with persistent atelectasis. Intra-operatively, 300 ml of serous straw colored pleural fluid were removed and strands of adhesive fibrinous tissue were identified. Tan fibrinous pleural peel was seen trapping the left lower lobe. Pathology of pleural tissue demonstrated fibroconnective tissue with acute and chronic inflammation and extensive necrosis. Francisella tularensis was ultimately identified from the pleural fluid culture by polymerase chain reaction and direct fluorescent antibody testing. He was treated with streptomycin, clinically improved and discharged home. 2. Discussion The earliest description of tularemia was in Japan in the year 1837. It is caused by the gram-negative coccobacillus, Francisella tularensis and has various names such as ‘‘rabbit fever’’, ‘‘deer-fly fever’’, ‘‘Ohara fever’’ and ‘‘Francis disease’’. The primary vectors are ticks and deer flies. However, it can also be spread through other arthropods. The incidence rate is less than 1 per 100,000. Person to person transmission has not been reported, consequently there is no role for isolation. It can be spread by
196
K. Navatha et al. / Respiratory Medicine CME 3 (2010) 195–197
Fig. 1. Chest X-ray showing left sided pleural effusion.
inoculation of the skin or mucous membranes with blood or tissue while handling infected animals (1). It can also be transmitted by contact with fluids from infected flies or ticks, bites of infected ticks, or handling or eating insufficiently cooked rabbits. Finally, drinking contaminated water or breathing dust that has been contaminated with this bacterium is another source of transmission. Tularemia has six characteristic presentations. The ulceroglandular form is the most common type representing 75% of all presentations. The glandular, oropharyngeal, pneumonic, oculoglandular, and typhoidal forms are other manifestations of tularemia(2). The pneumonic form as was diagnosed in our patient, is spread by inhalation of aerosolized Francisella tularensis or by secondary infection from another form of tularemia. They can present with sore throat, swelling of the lymph nodes in the lungs, abrupt onset of fever, chills, headache, muscle aches, joint pains, dry cough, and progressive weakness. Tularemic pneumonia is usually complicated by pleural involvement resulting in effusions. Pleurisy and pleural effusion without pneumonia can occur and is an uncommon presentation of tularemia. The incidence of pleural effusion increases with the duration of the disease and is often bilateral. It is usually a turbid or serosanguinous exudative effusion
Fig. 2. (a) Computed tomography of the chest showing consolidation in the left lower lobe with air bronchograms and pleural effusion. (b) Computed tomography of the chest mediastinal view showing left sided pleural effusion.
with high protein values and a predominance of either lymphocytes or neutrophils (3). However, unlike typical parapneumonic effusions, the pleural fluid glucose and pH levels are not low. Pleuropulmonary tularemia causes diagnostic difficulties and may be confused with tuberculous pleurisy. Like tuberculous effusion, tularemia effusions can be T-lymphocyte rich with high adenosine deaminase(ADA), lysozyme(LZM) and B2 microglobulin concentration(4). Nonetheless, a definitive diagnosis of tularemia is made by culture(5).
3. Conclusion Tularemia should be considered in the differential diagnosis in a patient presenting with exudative pleural effusion with extremely high LDH and alkaline PH. A careful history taking of recent travel or camping must be obtained. It remains unclear if our patient acquired tularemia either by aerosolization or by an arthropod vector bite. Conflict of interest Fig. 3. Gram negative coccobacillus.
Neither author has any conflict of interest.
K. Navatha et al. / Respiratory Medicine CME 3 (2010) 195–197
References 1. Craven RR, Hall JD, Fuller JR, Taft-Benz S, Kawula TH, et al. Francisella tularensis invasion of lung epithelial cells. Infect Immun 2008 Jul;76(7):2833–42. Epub 2008 Apr 21. 2. Hepburn MJ, Simpson AJ. Tularemia: current diagnosis and treatment options. Expert Rev Anti Infect Ther 2008 Apr;6(2):231–40.
197
3. Funk LM, Simpson SQ, Mertz G, Boyd J. Tularemia presenting as an isolated pleural effusion. West J Med 1992 Apr;156(4):415–7. 4. Pettersson T, Nyberg P, Nordstrom D, Riska H. Similar pleural fluid findings in pleuropulmonary tularemia and tuberculous pleurisy. Chest 1996;109:572–5. 5. Dennis DT, Inglesby TV, Henderson DA, Bartlett JG, Ascher MS, Eitzen E, et al. Tularemia as a biological weapon: medical and public health management. JAMA 2001 Jun 6;285(21):2763–73.