Tularemia In A 14-Year-Old Female Pediatric Patient – A Case Report

Case Report

A previously healthy 14-year-old girl from Ukraine was referred to our pediatric hematology and oncology department due to a large tender mass below the right groin. Two weeks prior, the family had been hiking in a local forest. She had had several tick bites along the right inner thigh. The day after the hike she developed a fever. No other systemic symptoms were present. The mass (4 cm+×+9 cm) was non-tender, warm and erythematous ([Fig. 1]). Sonography demonstrated several enlarged lymph nodes.

Fig. 1 Preoperative findings. Swelling of the lymph nodes below the right groin.

Further physical exam as well as lab results were unremarkable. We suspected Lyme disease and started oral therapy with doxycycline but serology came back negative for infection with Borrelia burgdorferi, and antibiotic treatment was switched to amoxicillin-clavulanic acid for five days. Due to the lack of a clinical response, intravenous therapy with ampicillin-sulbactam was initiated.Again, no clinical response was observed. Therefore, surgical abscess incision with flap insertion and biopsy was carried out, followed by daily irrigations.

Histologically, the biopsy revealed epithelioid granulomatous inflammation with localized necrosis. The PCR was positive for DNA of Francisella tularensis. A blood sample sent to the national reference center for tularemia in Germany confirmed the diagnosis of tularemia. High titers of IgM and IgG antibodies against the lipopolysaccharide of Francisella tularensis were detected (1:64000 and 1:28000 resp., cut of < 1.500). Upon diagnosis oral doxycycline was reinitiated for another 20 days. The drain was removed 14 days postoperatively ([Fig. 2]). Wound healing was without complications and the patient remained without any new symptoms at follow-up appointments in our clinic.

Fig. 2 Postoperative findings.

Publication History

Article published online:
01 March 2024