The n e w e ng l a n d j o u r na l of m e dic i n e

Images in Clinical Medicine

Chana A. Sacks, M.D., Editor

Glandular Tularemia

Laura Marks, M.D., Ph.D.

Barnes–Jewish Hospital
St. Louis, MO
marks@wustl.edu

Andrej Spec, M.D.

Washington University in St. Louis
St. Louis, MO

A
68-year-old man from Missouri presented to the primary care clinic with a history of 1 week
of fever followed by 2 months of progressive, painful swelling on the right side of his neck. Approximately
2 days before the onset of the patient’s symptoms, his outdoor cat died from a subacute illness; a veterinarian
had diagnosed feline leukemia without laboratory testing, and the cat had been treated with prednisone, which the
patient administered. The patient’s physical examination revealed three erythematous, tender lymph nodes. The
remainder of the physical examination was normal. Serologic testing with IgM antibody was positive for Francisella
tularensis (titer, 1:1280). A diagnosis of glandular tularemia was made. Glandular tularemia is the second most common
manifestation of tularemia after the ulceroglandular form. Because culture requires biosafety level 3 conditions,
diagnosis is often confirmed serologically. Domestic cats can become infected through the consumption of infected
prey and can transmit the bacteria to humans. The patient was treated with doxycycline for 4 weeks; the lesions
improved within 5 days and resolved within 3 weeks.
DOI: 10.1056/NEJMicm1801531
Copyright © 2018 Massachusetts Medical Society.

n engl j med 379;10 nejm.org September 6, 2018 967

The New England Journal of Medicine
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