Tularemia -- New Jersey

On December 3, 1985, a 67-year-old woman died from tularemia in a New Jersey hospital. She had been admitted 7 days previously with a metabolic acidosis secondary to combined dehydration and sepsis. On admission, she had an "unhealing sore" on the first finger of her right hand. Initial treatment included gentamicin and cefazolin, as well as insulin for uncontrolled, late-onset diabetes. After 3 days, the treatment was changed to streptomycin. Despite these measures, disseminated intravascular coagulation, respiratory failure, and hypotension developed, and the woman died.

The case history showed that on November 9, 1985, an 18-year-old neighbor had shot two rabbits behind his home in Gloucester County, New Jersey. After eviscerating the animals, he gave them to the patient and her 64-year-old husband, who skinned and froze the rabbits. During the summer, the young man had noticed several dead rabbits around his house and had attributed their deaths to insecticide that had been sprayed on local fields. One of the two rabbits he shot was noted to be losing its fur.

Two days after dressing out the rabbits, the young man became ill with an ulcerated hand lesion, axillary lymphadenopathy, and a fever. He was examined at the local hospital; no diagnosis was made, but he was treated with antipyretics. On November 23, his two neighbors--the recipients of the rabbits--were admitted to the local hospital. They both had sepsis and hand lesions. On November 26, following instructions from the hospital, the young hunter was started on streptomycin, and he recovered rapidly.

The woman's original titer for tularemia, drawn November 23, was less than 20. Her titer rose to 160 after 10 days. First samples from both men were drawn late in the disease. The hunter's first blood specimen was drawn on November 29, when his titer was 1,280. It was reported as 2,560 after 7 days. Blood specimens from the husband were drawn December 3, when his titer was 320, and the level rose to 1,280 after 14 days.

The two rabbits were sent to CDC for analysis. Cultures from the bone marrow of both animals grew Francisella tularensis. Reported by WE Parkin, DVM, State Epidemiologist, New Jersey State Dept of Health; Div of Field Svcs, Epidemiology Program Office, Div of Bacterial Diseases, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note:Six cases of tularemia had been reported in New Jersey over the 5-year period prior to this outbreak. One case, in 1985, was also associated with rabbits. No tularemia deaths had been reported in the state in the previous 5 years.

The association between rabbits and human tularemia was first documented in 1913 (1), and rabbit contact was implicated in 90% of the more than 14,000 cases reported through 1944 (2). Although bloodsucking anthropod vectors have accounted for an increasing percentage of cases in more recent years, rabbits continue to be an important source of infection (3).

In the United States, wild rabbits of the genus Sylvilagus (cottontails, marsh rabbits, and swamp rabbits) present the greatest hazard (2). Jack rabbits and snowshoe hares are susceptible to tularemia but have rarely been implicated as direct sources of human infection. The domestic rabbit (Oryctolagus cuniculus) has not been documented as a source of human tularemia (2).

Exposure of the skin or conjunctiva to blood and other infectious tissue while skinning and dressing rabbits account for most cases. Ingestion of inadequately cooked meat has also been implicated. In some instances pulmonary tularemia has resulted from breathing aerosols generated while handling unopened rabbits or merely by poking at a dead rabbit with a stick (4,5). Indirect transmission from rabbits to humans may result from bites by pet animals or deerflies (6,7).

In 1939, the peak incidence year in the United States, 2,291 cases (17.5/1,000,000 population) were reported (2). Only 291 cases (1.2/1,000,000 population) were reported in 1984.

References

1. Wherry WB, Lamb BH. Infection of man with Bacterium tularense. J Infect Dis 1914;15:331-40.

2. Jellison WL. Tularemia in North America 1930-1974. Missoula, Montana: University of Montana, 1974.

3. Boyce JM. Recent trends in the epidemiology of tularemia in the United States. J Infect Dis 1975;131:197-9.

4. Martone WJ, Marshall LW, Kaufmann AF, Hobbs JH, Levy ME. Tularemia pneumonia in Washington, DC. A report of three cases with possible common-source exposures. JAMA 1979;242:2315-7.

5. Halsted CC, Kulasinghe HP. Tularemia pneumonia in urban children. Pediatrics 1978;61:660-2.

6. Evans ME, McGee ZA, Hunter PT, Schaffner W. Tularemia and the tomcat. JAMA 1981;246:1343.

7. Klock LE, Olsen PF, Fukushima T. Tularemia epidemic associated with the deerfly. JAMA 1973;226:149-52.

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