Clinical Signs and Symptoms of Tularemia

Key points

  • Tularemia is caused by infection with the bacteria Francisella tularensis.
  • Ticks that transmit F. tularensis bacteria to humans include the American dog tick (Dermacentor variabilis), Rocky Mountain wood tick (D. andersoni), and lone star tick (Amblyomma americanum). Note it is NOT transmitted by the same ticks that transmit Borrelia burgdorferi, the agent of Lyme disease.
An ulcer on a person's thumb caused by Francisella tularensis.

Signs and symptoms

Incubation period

3–5 days (range 1–21 days)

Generalized signs and symptoms

  • Fever, chills
  • Headache
  • Malaise, fatigue
  • Anorexia
  • Myalgia
  • Chest discomfort, cough
  • Sore throat
  • Vomiting, diarrhea
  • Abdominal pain

Specific presentations

The clinical presentation of tularemia depends on the route of inoculation and other factors.

(Ulcero) Glandular: Usually occurs following a tick or deer fly bite or after handling an infected animal.

  • Localized lymphadenopathy
  • Cutaneous ulcer at infection site (not always present)
An ulcer on a person's thumb caused by Francisella tularensis.
An ulcer on a person's thumb caused by Francisella tularensis.

Oculoglandular: Occurs when the bacteria enter through the eye, for example when a person touches their eye after handling infectious material.

  • Photophobia
  • Excessive lacrimation
  • Conjunctivitis
  • Preauricular, submandibular and cervical lymphadenopathy
Cervical lymphadenopathy with fistula
Cervical lymphadenopathy with fistula. Photo credit: Reprinted from Çağlı, S., Vural, A., Sönmez, O. et al. Tularemia: a rare cause of neck mass, evaluation of 33 patients. Eur Arch Otorhinolaryngol268, 1699–1704 (2011). https://doi.org/10.1007/s00405-011-1722-8
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Oropharyngeal: Occurs after eating or drinking contaminated food or water.

  • Severe throat pain
  • Exudative pharyngitis or tonsillitis
  • Cervical, preparotid, and/or retropharyngeal lymphadenopathy

Pneumonic: Occurs after breathing dusts or aerosols containing the bacteria or secondary to other untreated forms of tularemia.

  • Cough (dry or productive)
  • Substernal tightness
  • Pleuritic chest pain
  • Hilar adenopathy, infiltrate, or pleural effusion may be present on chest imaging

Typhoidal:

  • Characterized by any combination of the general symptoms, without localizing symptoms of other specific presentations
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Content Source:
National Center for Emerging and Zoonotic Infectious Diseases (NCEZID)
  • Centers for Disease Control and Prevention. Tularemia¡ªUnited States, 2001-2010. MMWR 62(47): 963¨C966.
  • Dennis D, Inglesby TV, Henderson DA, et al. . JAMA 2001. 285(21): 2763¨C2773.
  • Dietrich EA and Petersen JM: Francisella. In: Carroll KC, Pfaller MA, Landry ML, et al, eds. Manual of Clinical Microbiology. 12th ed. 2019. ASM Press, Washington DC.
  • Nigrovic LE, Wingerter SL. . Infect Dis Clin North Am. 2008;22(3):489-504.
  • Penn RL. Francisella tularensis (Tularemia). In: Mandell GL, Bennett JE, Dolin R, editors. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 8th ed. Philadelphia, PA:Elsevier/Saunders; 2015. p. 2590¨C2602.
  • Feldman KA, Enscore RE, Lathrop SL, et al. . NEJM 2001; 345: 1601¨C1606.
  • World Health Organization. (?2007)?. WHO Guidelines on tularaemia. World Health Organization.