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Received Nov 1, 2017; Revised Dec 25, 2017; Accepted Jan 30, 2018
This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
1. Introduction
Francisella tularensis is the causative agent of the bacterial zoonotic disease tularemia, which is mostly endemic to the northern hemisphere [1]. The incidence of cases reported in the United States nearly doubled, from 180 in 2014 to 314 in 2015. New Jersey, however, continues to have a low incidence rate, with just 1 case reported in 2015 [2, 3]. Depending on the mode of inoculation, the presentation may vary, from localized papule formation and tender lymphadenitis to flu-like symptoms, exudative pharyngitis and tonsillitis [4, 5]. Such nonspecific presenting symptoms may overlap with symptoms of other diseases, including Kawasaki disease as in our case [6]. The appearance of a black eschar over the tender ulcerated lesion at the site of inoculation, which is a more specific diagnostic finding, may take 7–10 days to appear [7]. Hence, initial symptoms can be deceptive and require a high index of suspicion to make the correct diagnosis.
Here, we describe the case of an 18-month-old boy, presumptively treated for incomplete Kawasaki disease before being correctly diagnosed with tularemia.
2. Case Presentation
An 18-month-old male with a 3-day history of fever, cough, rhinorrhea, and a nonpruritic, diffuse confluent rash on the extensor surface of both legs presented to our Emergency Department (ED). Viral PCR panel was positive for parainfluenza virus, and he was discharged the same day. The following day, he developed swelling of both hands and feet with tender right-sided posterior cervical lymphadenopathy, along with persistent fever. Laboratory testing revealed leukocytosis and elevated inflammatory markers. Based on concerns of an incomplete presentation of Kawasaki disease, he was admitted to the hospital.
His hospital course and management are summarized in Figure 1.
[figure omitted; refer to PDF]
The patient was initially started on IVIG and high-dose aspirin as well as IV clindamycin as empiric therapy for lymphadenitis. Careful physical examination revealed a small 1 × 1 cm scab on the scalp (Figure 2). Upon further questioning, parents revealed that they had removed a tick from the area about 3 days...