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 [(b)(l)sec 3.4 (b)(2)]
                                            Ulceroglandular
tularemia generally occurs about 3 days after exposure (range,
2-10 days), and manifests as a cutaneous ulcer with regional
lymphadenopathy, fever, chills, headache, and malaise. With
typhoidal disease, the systemic clinical manifestations are
similar to those seen in the ulceroglandular form, but the
disease is not "contained" as a localized lesion. Typhoidal
disease occurs after inhalation of tularemia organisms; in the
latter, clinically and radiologically evident pneumonia may be
significant. Three to five days following inhalation, the
abrupt onset of fever, chills, headache, myalgia, and
prostration are seen, with a non-productive cough. Deposition
of organisms in the orophyarynx may also produce a pharynygeal
form of tularemia, with "ulceroglandular" type lesions
localized to the throat.

DIAGNOSIS

Specific Laboratory Diagnosis. Identification of
organisms by staining ulcer fluids or sputum is generally
not helpful. Routine culture is difficult due to unusual
growth requirements or overgrowth of commensual bacteria.
The diagnosis can be established retrospectively by serology.

THERAPY. Streptomycin is the treatment of choice. Gentamycin
is also effective. Although laboratory-related infections with
this organism are very common, human-to-human spread is unusual.

PROPHYLAXIS. A live-attenuated tularemia vaccine is available
as in investigational new drug (IND). This vaccine has been
administered to more than 5,000 persons without significant
adverse reactions, and is of proven effectiveness in preventing
laboratory-acquired typhoidal and pneumonic tularemia.

The use of antibiotics for prophylaxis against tularemia is
controversial. At best, onset of disease will be delayed
somewhat.

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