When viewing this topic in a different language, you may notice some differences in the way the content is structured, but it still reflects the latest evidence-based guidance.


Last reviewed: 30 Oct 2023
Last updated: 09 Jun 2023



History and exam

Key diagnostic factors

  • fever
  • lymphadenopathy
  • painful skin ulcer
  • unilateral conjunctivitis
More key diagnostic factors

Other diagnostic factors

  • headache
  • malaise/fatigue
  • myalgia
  • anorexia
  • abdominal pain
  • vomiting
  • rales
  • nonproductive cough/dyspnea
  • sore throat
  • photophobia
  • vision impairment/loss
  • jaundice, hepatosplenomegaly, diarrhea
  • positive Kernig/Brudzinski sign, stiff neck
Other diagnostic factors

Risk factors

  • tick exposure
  • biting fly exposure
  • contact with infected animals
  • yard work in areas where infected animals live
  • spring or summer season
More risk factors

Diagnostic investigations

1st investigations 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
More 1st investigations to order

Investigations to consider

  • chest x-ray
  • lumbar puncture
  • histopathology
More investigations to consider

Emerging tests

  • antigen detection in urine

Treatment algorithm


tularemia without meningitis

tularemic meningitis



William A. Petri, Jr., MD, PhD, FACP
William A. Petri, Jr.

Wade Hampton Frost Professor of Epidemiology

Professor of Medicine, Microbiology, and Pathology

Chief, Division of Infectious Diseases and International Health

University of Virginia




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




CH declares that he has no competing interests.

Beth Kirkpatrick, MD

Assistant Professor

Infectious Diseases

University of Vermont College of Medicine




BK declares that she has no competing interests.

  • Tularemia images
  • Differentials

    • Tularemic bacteremia
    • Cat scratch disease
    • Toxoplasmosis
    More Differentials
  • Guidelines

    • Tickborne diseases of the United States: a reference manual for health care providers
    • Practice guidelines for the diagnosis and management of skin and soft tissue infections
    More Guidelines
  • padlock-lockedLog in or subscribe to access all of BMJ Best Practice

Use of this content is subject to our disclaimer