Typhoidal Tularemia: 2 Familial Cases

Eastern France was not known as a region endemic for tularemia until year 2006. We report on 2 cases of typhoidal tularemia in Eastern France, a 43-year-old hospitalized woman and her husband. Diagnosis was established after fever clearance on serodiagnosis criteria. The source of infection is unclear. As persons in the same family may likely be exposed to a common zoonotic source of infection, tularemia should be considered in the etiologies of familial fever epidemics. 1. Introduction Tularemia belongs to zoonotic diseases. Its recrudescence was recently described in Eastern France [1]. We herein report and review on 2 familial cases of tularemia. 2. Case Presentation A 43-year-old previously healthy female resident of a rural area in Eastern France was admitted in September 2010 for a suspected meningoradiculitis. She had a recent history of fever associated to mild cough, myalgia, and polyarthralgia. Her husband suffered similar flu-like symptoms one day before his wife. Fever started 12 days after a short family stay in Northern Italy. Physical examination results were unremarkable and a chest X-ray was normal. Results of a laboratory work found elevated C-reactive protein (217？mg/L) and liver function tests (alanine amino transferase level:？2？N). An arboviral cause of fever was considered by the GP and she was symptomatically treated. Flu-like symptoms lasted 10 days but epigastralgia and a left hemithoracic pain (T10-T11) appeared with no skin eruption. Laboratory work found persisting C-reactive protein (126？mg/L) and liver function tests (alanine amino transferase level:？2.5？N) elevated values; lipasemia was normal. A gastroscopic examination and a thoracoabdominal CT scan were unremarkable. Two weeks after fever resolution, a meningoradiculitis was suspected because of persisting left hemithoracic pain, and the patient was referred to hospitalization. A laboratory work up found elevated C-reactive protein (67？mg/L) with normal procalcitonin values. Results of blood and urine cultures were negative. CSF was normal as were the results of a spine RMI. Pregabalin prescription resulted into symptoms improvement. On the basis of serologic results, the following diseases could be ruled out: viral infections (HIV, EBV, CMV, hepatitis B and C, dengue, Chikungunya, Toscana virus, West Nile, TBE), Lyme borreliosis, Bartonella henselae infection, rickettsiosis, Q fever, brucellosis, Legionella, Mycoplasma, Chlamydia spp. infections, and yersiniosis. Serum sample was positive for tularemia by the microagglutination (320, threshold of 160) and