Summary
Definition
History and exam
Key diagnostic factors
- fever
- lymphadenopathy
- painful skin ulcer
- unilateral conjunctivitis
Other diagnostic factors
- headache
- malaise/fatigue
- myalgia
- anorexia
- abdominal pain
- diarrhea
- vomiting
- rales
- nonproductive cough
- dyspnea
- chest tightness
- pleuritic pain
- sore throat
- photophobia
- vision impairment/loss
- excessive lacrimation
- jaundice, hepatosplenomegaly, diarrhea
- positive Kernig/Brudzinski sign, stiff neck
Risk factors
- tick exposure
- biting fly exposure
- contact with infected animals
- yard work in areas where infected animals live
- spring or summer season
- ingestion of contaminated food or water
Diagnostic tests
1st tests to order
- CBC
- serum electrolyte levels
- LFTs
- serum creatine kinase
- urine dipstick for blood
- erythrocyte sedimentation rate
- serology
- blood culture
- specimen culture
- polymerase chain reaction (PCR) of ulcer swab or lymph node aspirate
Tests to consider
- CXR
- lumbar puncture
- histopathology
Treatment algorithm
naturally occuring
intentional release
Contributors
Authors
Jennifer M. Hendrick, MD
Assistant Professor of Medicine
University of Virginia Health System
Division of Infectious Diseases and International Health
Charlottesville, VA
Disclosures
JMH declares that she has filed a patent application for dupilumab for treatment of COVID-19. However, there is no current commercial activity related to this.
Acknowledgements
Dr Jennifer M. Hendrick would like to gratefully acknowledge Dr William A. Petri, Jr., a previous contributor to this topic.
Disclosures
WAP declares that he has no competing interests.
Peer reviewers
Christopher Huston, MD
Assistant Professor of Medicine
Division of Infectious Diseases
University of Vermont College of Medicine
Burlington, VT
Disclosures
CH declares that he has no competing interests.
Shauna Gunaratne, MD, MPH, DTM&H, CTropMed
Assistant Professor of Clinical Medicine
Department of Medicine
Division of Infectious Diseases
Columbia University Irving Medical Center
New York, NY
Disclosures
SG declares that she has no competing interests.
Peer reviewer acknowledgements
BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.
Disclosures
Peer reviewer affiliations and disclosures pertain to the time of the review.
References
Key articles
Centers for Disease Control and Prevention. Tickborne diseases of the United States: a reference manual for health care providers, sixth edition. Aug 2022 [internet publication].Full text
Nelson CA, Meaney-Delman D, Fleck-Derderian S, et al. Tularemia antimicrobial treatment and prophylaxis: CDC recommendations for naturally acquired infections and bioterrorism response - United States, 2025. MMWR Recomm Rep. 2025 Oct 2;74(2):1-33.Full text Abstract
World Health Organization (WHO). WHO guidelines on tularaemia. 2007 [internet publication].Full text
Centers for Disease Control and Prevention. Tularemia: clinical testing and diagnosis for tularemia. May 2024 [internet publication].Full text
Centers for Disease Control and Prevention. Tularemia: clinical care of tularemia. Jan 2026 [internet publication].Full text
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
Differentials
- Tularemic bacteremia
- Cat scratch disease
- Toxoplasmosis
More DifferentialsGuidelines
- Tularemia antimicrobial treatment and prophylaxis: CDC recommendations for naturally acquired infections and bioterrorism response
- Tickborne diseases of the United States: a reference manual for health care providers
More Guidelines
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