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Background Francisella tularensis , the causative agent of tularemia, is endemic throughout the Northern Hemisphere and requires as few as 10 organisms to cause disease, making this potential bioterrorism agent one of the most infectious bacterial pathogens known. Aminoglycosides, tetracyclines, and, more recently, fluoroquinolones are used for treatment of tularemia; however, data on the relative effectiveness of these and other antimicrobial classes are limited. Methods Nine databases, including Medline, Global Health, and Embase, were systematically searched for articles containing terms related to tularemia. Articles with case-level data on tularemia diagnosis, antimicrobial treatment, and patient outcome were included. Patient demographics, clinical findings, antimicrobial administration, and outcome (eg, intubation, fatality) were abstracted using a standardized form. Results Of the 8878 publications identified and screened, 410 articles describing 870 cases from 1993 to 2023 met inclusion criteria. Cases were reported from 35 countries; more than half were from the United States, Turkey, or Spain. The most common clinical forms were ulceroglandular, oropharyngeal, glandular, and pneumonic disease. Among patients treated with aminoglycosides (n = 452 [52%]), fluoroquinolones (n = 339 [39%]), or tetracyclines (n = 419 [48%]), the fatality rate was 0.7%, 0.9%, and 1.2%, respectively. Patients with pneumonic disease who received ciprofloxacin had no fatalities and the lowest rates of thoracentesis/pleural effusion drainage and intubation compared to those who received aminoglycosides and tetracyclines. Conclusions Aminoglycosides, fluoroquinolones, and tetracyclines are effective antimicrobials for treatment of tularemia, regardless of clinical manifestation. For pneumonic disease specifically, ciprofloxacin may have slight advantages compared to other antimicrobials. [ABSTRACT FROM AUTHOR]

Bacterial abortive agents such as Brucella spp., Salmonella spp., Campylobacter spp., Listeria spp. cause serious infections that lead to significant economic losses in cattle and sheep breeding. These bacteria can be easily cultured under in vitro laboratory conditions. Abortions caused by intracellular bacteria such as Coxiella burnetii (C. burnetii), Chlamydophila abortus (C. abortus) and Francisella tularensis (F. tularensis) are less prevalent in abortive cases and the diagnosis of these bacteria, many of which need to cell culture for cultivation and biosafety level-3 laboratory facilities for safe working, can be made by PCR. In this study, it was aimed to determine the molecular prevalence of C. burnetii, C. abortus and F. tularensis agents, which were neglected during the diagnosis of abortions, in cattle and sheep collected from different regions of Türkiye. A total of 395 clinical materials were analyzed via agent-specific commercial Real-Time PCR. As a result, the molecular prevalence of F. tularensis, C. burnetii and C. abortus was determined as 14%, 2.9% and 2.28%, respectively. F. tularensis in cattle clinical samples and C. burnetii in sheep clinical samples were not found. This is the first report that F. tularensis was found as an agent in an abortive material in Türkiye. Although it differs in terms of prevalence, it has been determined that these microorganisms, which are neglected in routine diagnosis, can be spread with aborted materials, especially vaginal discharge, which may pose a risk of transmission. [ABSTRACT FROM AUTHOR]

Objective: Tularemia is a rare and often overlooked zoonotic infection. While the ulceroglandular and glandular types are observed most frequently in epidemics originating in Europe, the oropharyngeal type is most common in Türkiye. The most common clinical findings are lymphadenopathy, skin rash, and tonsillitis. The aim of this study was to investigate the frequency of tularemia in Tokat, a province located in the Central Black Sea Region of Türkiye. Materials and Methods: The data of patients diagnosed with tularemia at Tokat Gaziosmanpaşa University Faculty of Medicine Training and Research Hospital between January 2011 and July 2021 were retrospectively analyzed. Laboratoryconfirmed cases were included in the study. Sociodemographic characteristics, risk factors, clinical and laboratory findings, treatments, and post-treatment follow-up of the cases were evaluated. Results: Tularemia was detected in 20 patients. A total of 80% patients lived in a village, 65% were engaged in agriculture as a profession, and 60% in animal husbandry. The most important possible sources of contamination were rodents near the house (40%) and non-chlorinated drinking water (50%). Among 20 cases, 57% were oropharyngeal tularemia, 95% were treated with monotherapy or combinations containing aminoglycosides, and 50% with surgical lymph node drainage. Conclusion: Tularemia is a rare infection in Tokat Province. But it should be considered in the differential diagnosis of patients living in rural areas who present with fever, sore throat, and cervical lymphadenopathy that is not responsive to beta-lactam agents. [ABSTRACT FROM AUTHOR]

Objective: Tularemia is a zoonotic disease that causes epidemics in Turkey. An increase in tularemia cases was noticed in the province of Muş compared to previous years. With this study, we aimed to increase the awareness of tularemia in the region by sharing the characteristics of the cases. Methods: The epidemiological, demographic, and clinical characteristics of tularemia cases seen in the province of Muş between 2017-2019 were retrospectively analyzed. Only confirmed cases were included. Results: Fifty cases were seen between 2017-2019. 52% were male; the average age was 23 (3-66), and 44% were 18 years or younger. The average admission time to the hospital was 23 days (3-79). Lymphadenopathy (LAP) (100%), sore throat (78%), weakness (66%), and loss of appetite (60%) were among the most common symptoms and signs at the onset of the disease. Oropharyngeal form (90%) was seen in most of the cases. 96% of the patients lived in rural areas, and 84% of them were using mains water as drinking water. Mains water chlorination rate was 30%. Most cases were seen in autumn and winter (76%). Similar clinical presentations were observed in 46% of the people in the neighborhood. No mortality was seen in the patients. Conclusion: Data of two tularemia epidemics and six sporadic cases in the region within three years were presented. It should not be forgotten that tularemia is also seen in the pediatric age group in our region. Tularemia should be considered in patients of all age groups who present with complaints of LAP, sore throat, weakness, anorexia, and fever, especially during autumn and winter. Contact with contaminated water should be questioned in patients with atypically located LAP, and detailed epidemiological history should be taken. Taking sanitation measures and making prompt investigations are significant in preventing possible epidemics in areas with an increase in tularemia cases. [ABSTRACT FROM AUTHOR]

Ixodes ricinus is a potential vector for some of the tick-borne microorganisms that can cause significant diseases in animals and humans. This study aims to determine the prevalence of Anaplasma, Rickettsia, Bartonella, and Francisella species in host-seeking ticks collected from the forest areas in the Sinop region located in the northernmost part of Turkey. Between May and July 2017, a total of 135 tick pools formed from 2571 of the 2734 ticks collected out of the vegetation. Samples of each pool were homogenized and analyzed by PCR. Infection prevalence was statistically analyzed in view of the maximum likelihood estimation (MLE) with a 95% confidence interval (CI). DNA of the infectious agents was determined only in the adult and nymph pools of I. ricinus. MLE values of Anaplasma spp. and Bartonella spp. in 58 pools formed from 517 of I. ricinus adults were 1.20% (95% CI: 0.50–2.49) and 0.80% (95% CI: 0.26–1.91), respectively. In 42 pools generated from 1222 of I. ricinus nymph, MLE values of infection prevalence for Anaplasma spp. and Bartonella spp. were calculated to be 0.17% (95% CI: 0.03–0.54) and 0.34% (95% CI: 0.11–0.82) in respective order. MLE values for Rickettsia spp. were 7.55% (95% CI: 5.21–10.69) and 0.52% (95% CI: 0.22–1.083) for the adult and nymph I. ricinus, respectively. The DNA of Francisella tularensis was not detected in any tick pool. The outcomes of this research are the first molecular evidence of Bartonella spp. and Bartonella henselae in questing I. ricinus in Turkey. The results also suggested that I. ricinus plays considerable roles in enzootic transmission cycles of Anaplasma phagocytophilum, B. henselae, and Rickettsia monacensis in the northernmost region of Turkey. [ABSTRACT FROM AUTHOR]

Objective: Tularemia was first detected in Thrace region in our country and the outbreaks continued in the region over the following years. The fact that the agent has been identified in mice around Kaynarca in 2012 suggests the disease poses a risk for our region. Aim of this study was to investigate tularemia incidence and presence of Francisella tularensis in streams/mains water in a risky region of Thrace. Methods: In this study, seropositivity for tularemia was investigated in 13 villages, and 1 town in risky areas of the Thrace region. In January 2016, blood was drawn from 746 people and tularemia microagglutination tests were applied. Seropositivity was not detected. In December, 464 of 746 people were reached. Seroconversion was not observed. In addition, culture and polymerase chain reaction (PCR) procedures were applied to specimens collected from mains water and streams in 13 villages and 1 town. Results: The causative agent wasn't isolated from the cultures but F. tularensis DNAs were detected by PCR method in 2 stream, and 3 mains water samples. One of the streams passed through the village of Celaliye, which was very close to the Kaynarca, in which tularemia cases were seen in the past. The other was farther, passing through the Kavaklı town in which no cases has been reported. The mains water which were positive were from Hamzabey, Ceylanköy, and Tatarköy villages located around Kaynarca. Molecular examination after chlorination was repeated in the water sources in which positivity was detected, and it was seen that the agent was eliminated. Conclusions: In this study, incidence was calculated as zero, although the causative agent was found in the water. Although no seropositivity was detected, the detection of the agent by PCR in 5 water samples showed that the agents in the nature could reach the water resources. It has been observed that surveillance studies in risky areas could be effective in preventing possible outbreaks. [ABSTRACT FROM AUTHOR]

Background and Objectives: Francisella tularensis has a wide distribution in northern hemisphere of the world. Up to now, there was little information about the Francisella spp. situation in the environmental samples in Iran. In this study we aimed to determine the prevalence of Francisella spp. in the environmental samples in northwest of Iran. Materials and Methods: A total of 237 natural water samples from ponds, rivers, lakes, springs and other surface waters from north western provinces of Iran (Kurdistan and Western Azerbaijan) were collected from September to November 2015. All samples were cultured for Francisella and other bacterial species and Real Time TaqMan PCR was performed on the concentrated and DNA extracted samples. For detection of the presence of bacterial DNA in the samples, two different targets in the genome of Francisella, ISFtu2 and fopA were used. Results: Among the tested surface water samples, 40 (17.09%; 95% CI: 12.67–22.33%) and 12 (5.13%; 95%CI: 2.81–8.56%) samples were positive for ISFtu2 and fopA respectively. None of them was positive in culture. Conclusion: The prevalence of Francisella spp. in the environmental samples in the west of Iran is high and it is comparable with Turkey, Iran's neighboring country. Use of higher copy number genes or IS like ISFtu2 could improve the detection of this organism in the environmental samples. [ABSTRACT FROM AUTHOR]

Tularemia; caused by Francisella tularensis is a zoonotic disease which can be seen endemic in the northern hemisphere. The distribution of tularemia cases according to years and the characteristics of the disease in Ankara province were evaluated in this descriptive study. The number of tularemia cases according to years in Ankara were as follows: 129 cases in 2010, 349 in 2011, 87 in 2012, 2 in 2013, 0 in 2014, 23 in 2015, 86 in 2016, 16 in 2017 and 4 in 2018. 52.3% of cases seen in the years 2010- 2018 were female (n = 364) and 47.7% (n = 332) were male and the mean age was 38.99 ± 18.82. In these cases, the use of waterwork was 66.7%, the use of public fountains was 40.3%, the use of well water was 7.0%, the presence of rodents around was 25.6%. To control tularemia, well water, spring water and fountains outside the grid system must be controlled; used water tanks must be maintained and cleaned at regular intervals. It is important that the water against microbiological contamination are chlorinated by automatic devices and the residual chlorine measurements are made without interruption. [ABSTRACT FROM AUTHOR]

Background/aim: The aim of the current study was to investigate the presence of antibodies against Francisella tularensis in individuals in different occupations that have contact with animals in the Kars region of northeastern Turkey. Materials and methods: A total of 201 blood samples specifically including 103 farmers, 45 clinical veterinarians, 42 butchers, and 11 hunters were analyzed. The results of the study were reported in relation to some sociodemographic features (age, sex, occupation, and experience) of the volunteers. The presence of antibodies was determined by a microagglutination (MA) test. In addition, positive sera were confirmed using an ELISA kit. Results: Fifteen (7.46%) individuals, including fourteen farmers and one clinical veterinarian, were found to be positive for F. tularensis by both MA and ELISA with a titer range of 1/10 to 1/160. The highest seroprevalence rate was observed in farmers (13.59%), followed by clinical veterinarians (2.22%). The occurrence of tularemia was found to increase with age. Conclusion: Though the main route of tularemia outbreaks is water-borne in Turkey, it was determined that people whose occupations bring them into contact with animals are at risk. Similar studies are recommended in order to further clarify the epidemiology of the disease in the northeast of Turkey. [ABSTRACT FROM AUTHOR]

Tularemia is a zoonotic infection caused by Francisella tularensis and has gained renewed importance since there has been a recent increase in the number of human cases in several countries across the world. In this study the existence of F. tularensis in rodents and in water was investigated by culture and PCR techniques. Also, F. tularensis specific antibodies were investigated by serological methods in sheep. At the end of the study, F. tularensis was isolated from one water sample by culture and PCR techniques, on the other hand, 27.6% seropositivity was detected in the blood samples of sheep. [ABSTRACT FROM AUTHOR]

The article reports on a study on tularemia in 100 children in Turkey from September 2009 to November 2012. The study examined the diagnosis, treatment and prognosis of the zoonotic disease which is caused by Francisella tularensis in children 3-18 years of age. Findings showed that cervical lymphadenopathy and elevated erythrocyte are the common physical signs and laboratory findings.

Tularemia is considered to have existed in Anatolia for several thousand years. There are suspicions regarding its use in biological warfare in the Neshite-Arzawan conflict. The causative agent of tularemia may have first been used as a biological weapon in 1320-1318 BC. The disease has recently become a significant re-emerging disease globally as well as in Turkey. In the period of 2001-2010, Kosovo had the highest annual incidence in Europe at a rate of 5.2 per 100,000. Sweden, Finland, Slovakia, Czech Republic, Norway, Serbia-Montenegro, Hungary, Bulgaria, and Croatia follow with rates of 2.80, 1.19, 1.0, 0.81, 0.42, 0.4, 0.36, 0.21, and 0.15 per 100,000 people, respectively. Tularemia in Turkey was first reported in the soldiers living in the region very close to the Kaynarca Stream of Thrace in 1936. It has started to gain more and more importance, especially in recent decades in Turkey, due to a very high number of cases and its spread throughout the country. A total of 431 tularemia cases were recorded in Turkey in 2005, but a significant reduction was observed in the number of the cases in the next three years; the number of patients decreased to 71 in 2008. The number of cases increased again in 2009 and continued in subsequent years. The number of cases reached 428, 1531, 2151, and 607 in 2009,2010,2011, and 2012, respectively The number of cases peaked in 2011 in Turkey, and was in fact higher than the total number of cases in all European Union countries. The number of cases is higher in females than males in Turkey. In Turkey, 52% of cases of tularemia diagnoses occur from December to March and the most common clinical presentation is the oropharyngeal form caused by contaminated water. Rodents are the most likely sources of tularemia outbreaks in Turkey as well as in Kosovo. Organisms such as ticks, flies and mosquitoes are vectors of tularemia transmission to mammals. Because ticks can carry the bacteria by both transovarial and transstadial transmission, they play a role in the life cycle of tularemia as both reservoir and vector.

Introduction: Tularemia is a zoonotic disease caused by Francisella tularensis. Here we present an epidemic occurring in Bolu province, located in northwestern Anatolia in Turkey, and some features of the cases. Methodology: The data was provided by the Bolu Provincial Health Directorate. All of the antibody response tests were studied in the National Health Institute (formerly named Refik Saydam Hygiene Department), the reference laboratory of the Ministry of Health of the Turkish Republic. A total of 393 individuals were tested by microagglutination test (MAT) for tularemia between 2006 and 2011. A total of 218 patients whose demographical data were available were included in the study; 83 were accepted as the patient group and 135 were the controls. Of the patients, 31 (37.3%) were male and 52 (62.7%) were female. Results: Fever (p < 0.001), URTI symptoms (p = 0.047), conjunctivitis (p = 0.004), and rash (p = 0.026) were significantly higher in the patient group. A positive association was found between MAT and fever (r = 0.324; p < 0.001), and a negative association was found between MAT and both lymphoadenopathy (r = -0.25; p = 0.013) and chills (r = -0.218; p = 0.035). Higher MAT titers were detected in oropharyngeal tularemia (r = 0.306; p = 0.003). Conclusions: In conclusion, tularemia must be considered in differential diagnosis in patients presenting with fever and LAP in non-endemic regions. Furthermore, water sources and contact with rodents must be investigated. [ABSTRACT FROM AUTHOR]

Summary: Background: Over the last two to three decades there has been a marked decrease in certain bacterial infections in Turkey. One of them is tuberculosis. Of note, statistics published by the Turkish Ministry of Health (MoH) show decreasing pulmonary tuberculosis (PTB), but on the other hand, increasing extrapulmonary tuberculosis (EPTB). The most common form of EPTB is tuberculous cervical lymphadenitis (TCL). The increase in the number of TCL cases despite the decline in cases of PTB is seen as a paradoxical issue. In contrast there has been an increase in the number of oropharyngeal tularemia cases in the last decade in Turkey. The aim of this study was to draw attention to the importance of differentiating between TCL and tularemia lymphadenitis, because these diseases may have a similar histopathological appearance. Methods: Thirty-two cases diagnosed as TCL were identified from the archives of a pathology laboratory (Patomer Pathology Laboratory, Bursa, Turkey). PCR tests for Francisella tularensis and Mycobacterium tuberculosis were carried out on the paraffin tissue blocks of these cases. At the same time, statistical data on PTB and EPTB for the period 1996–2010 were retrieved from the MoH and reviewed. Statistics related to tularemia, which has been diagnosed since 1988 and has been increasing in the last 10 years, were obtained from the Department of Zoonoses of the MoH. Results: Six out of 32 (19%) cases who had previously been diagnosed with ‘casseifying granulomatous lymphadenitis consistent with tuberculosis’ were found to be positive for tularemia by PCR test of the cervical lymph nodes. Conclusions: Oropharyngeal tularemia should be kept in mind in the differential diagnosis of cervical lymphadenitis in widespread geographic regions of the Northern Hemisphere, including the Asian continent. In particular, if granulomatous inflammation with necrosis is seen histopathologically, tularemia should be excluded before making the diagnosis of TCL. [ABSTRACT FROM AUTHOR]

Background: Tularemia is an infection caused by Francisella tularensis, which has a wide distribution in the northern hemisphere and diverse clinical manifestations. For decades, the drug of choice for the treatment of tularemia has been streptomycin, with tetracycline and chloramphenicol being used as alternatives. The purpose of the present study was to determine the in vitro antimicrobial susceptibility of a large panel of geographically diverse F. tularensis isolates from Turkey against traditional and newer antimicrobial agents. Methods: The antibiotic susceptibilities of 250 F. tularensis strains were examined using the Epsilometer test for 9 antimicrobial agents. Each isolate was identified by conventional and molecular techniques. Results: All the strains were confirmed biochemically and using a combination of species- and subspecies-specific polymerase chain reaction (PCR) assays to be F. tularensis subsp. holarctica. One isolate was assigned to F. tularensis subsp. holarctica biovar japonica based on erythromycin susceptibility, an ability to ferment glycerol, and the nucleotide sequence of the region of difference 1 (RD1). All strains were susceptible to aminoglycosides (streptomycin and gentamicin), tetracyclines (tetracycline and doxycycline), chloramphenicol, 2 fluoroquinolones (ciprofloxacin and levofloxacin), and rifampicin. In addition, all isolates except 1 had a minimal inhibitory concentration (MIC) for erythromycin of > 256 μg/ml. Conclusions: Since the fluoroquinolones showed the lowest MIC values and have advantages such as excellent bioavailability and activity, availability of oral formulations, and lower toxicities, they represent candidate therapeutic options in the first-line treatment of tularemia. To the best of our knowledge, this is the first report of the presence of F. tularensis subsp. holarctica biovar japonica outside Japan. [ABSTRACT FROM AUTHOR]

Tularemia is an endemic disease in Turkey. In this study, we aimed to detect Francisella tularensis by two methods from natural water supplies thought to cause tularemia epidemiologically. A total of 154 water specimens from three different outbreaks caused by drinking water were collected. Water specimens were cultured on antibiotic-added cysteine heart agar base with blood and incubated at 37°C in a humidified atmosphere containing 5% CO for 4-10 days. The suspected colonies were confirmed by F. tularensis antiserum (BD) and the real-time TaqMan polymerase chain reaction (PCR) method. DNA was isolated from samples obtained from filters. The primer and probe sets targeting the IS Ftu2 genome were used. A total of four F. tularensis isolates were obtained from 154 water samples. At the same time, the presence of F. tularensis DNA from 17 water specimens was shown by the real-time TaqMan PCR method. Although the DNA presence of F. tularensis has been detected from water sources by the PCR method in Turkey up to now, there has been no isolation directly from water specimens by culture. In this study, the determination of F. tularensis from water sources has been exhibited as the first data by both culture and real-time TaqMan PCR methods. [ABSTRACT FROM AUTHOR]

A 58-year-old woman was admitted to our hospital with a two week history of fever, and left axillary lymphadenopathy. She was living in a village endemic for tularemia, but she had no history of any animal contact or a tick bite. She had a wound on the second finger of her left hand which was the probable port of entry for Francisella tularensis. The clinical diagnosis of tularemia was confirmed by a microagglutination test. As this case demonstrated, other forms of tularemia other than oropharyngeal form prevalent in Turkey can be encountered among patients with fever and lymphadenopathy in endemic regions. [ABSTRACT FROM AUTHOR]

Abstract: Objective: We aimed to attract our colleagues’ attention to the oropharyngeal tularemia, which has been an infrequently diagnosed disease in otolaryngology clinics also becoming widespread in Turkey. Methods: A retrospective review of database of 3 patients was performed to find patients with Tularemia. The medical files, treatment charts, serological and PCR findings and radiological (magnetic resonance imaging), histopathological records of these patients were reviewed. Results: The study group consisted of 3 oropharyngeal tularemia patients. All of them presented with tonsillopharyngitis and cervical lymphadenitis and all were resistant to beta lactam or cephalosporin group antibiotics. Two patients had magnetic resonance imaging findings. All patients had positive serological tests. Strongly positive serological tests led to the diagnosis of tularemia. All patients had positive PCR and direct fluorescent antibody (DFA) test. All patients responded to systemic streptomycin treatment. Conclusion: In the daily practice of an otolaryngologist, it is not usual to diagnose a patient with oropharyngeal tularemia. Tularemia should be considered in the differential diagnosis of massive adenotonsillar enlargement and extensive necrotic cervical lymphadenopathy not responding to beta lactam antibiotics as a result of the rising number of tularemia outbreaks outside the classic endemic areas. [Copyright &y& Elsevier]

Objective: Several tularemia epidemics have been reported from many provinces in our country in recent years. We report the first tularemia epidemic occurring in Sivas, and some features of the cases. Methods: Twenty-nine patients admitted to the Infectious Diseases and Clinical Microbiology Clinic of Cumhuriyet University Hospital, between January 2009 and June 2010 were retrospectively investigated. Microagglutination method was used for serological diagnosis. Patients were reviewed and recorded for demographic, clinical and laboratory features. Results: 15 of the patients were male and 14 were female. The mean age was 41.8 years. The mean time between the onset of the symptoms and diagnosis was 38 days. Francisella tularensis was detected by polymerase chain reaction in lymph node aspirate from two patients. This epidemic was thought to be waterborne. In most of the cases (75.9%), the disease presented itself in the oropharyngeal form. The majority of the patients (93.1%) had cervical lymphadenopathy. Prior to diagnosis of tularemia, several antibiotic regimens ineffective for tularemia were given to 72.4% of the patients. Streptomycin and doxycycline combination was given to most of the patients (44.8%) for treatment. No mortality or sequela except for scar was observed. Conclusions: Clinicians should be careful for tularemia, even in non-endemic regions. Tularemia should be considered in the differential diagnosis of patients with tonsillopharyngitis and/or cervical lymphadenopathy. [ABSTRACT FROM AUTHOR]

The article presents a study on the genetic diversity of oropharyngeal tularemia in Turkey from December 2009 until January 2011. The zoonotic disease is caused by Francisella tularensis subspecie holarctica from contaminated water. Samples from 14 patients were taken for fine-needle lymph node aspiration, DNA extraction and polymerase chain reaction (PCR). It is suggested that the disease expands the known geographic range of these phylogenetic groups.

Limited knowledge is available regarding tularemia in pregnancy. A total of seven tularemia cases in pregnant women have been published in the literature. This report presents three new cases. Two of these cases improved without any treatment. The third case was treated with gentamicin. All three pregnancies reached full term without complication for either mother or child. [ABSTRACT FROM AUTHOR]