3/08/2012. ID consulted Repeat swabs Change Abx Refer

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1 3/08/202 ID consulted Repeat swabs Change Abx Refer Ultrasound : 2 epitrochlear lymph nodes (0 & 2mm) with extensive surrounding soft tissue oedema

2 Ongoing intermittent fevers with rigors Copious purulent discharge from two ulcers just proximal to the medial epicondyle of her right elbow R. axillary lymphadenopathy measuring 3x2.5cm, as well as bilateral supraclavicular lymphadenopathy Small well healed scar on the dorsum of the middle phalanx of her right index finger Admitted to hospital ULTRASOUND GUIDED DRAINAGE R AXILLA 6 mls of pus aspirated and sent for laboratory studies COMPUTER TOMOGRAPHY CHEST/ABDOMEN R axilla nodes, largest measuring 20x2mm L axilla nodes, largest measuring 8x6mm No other abnormalities Possum Bite D0 General M/C/S AFB & fungal culture β-lactams Augmentin DF Ciprofloxacin D4 D7 D25 Hospital Admission D47 D3 D30 Fever, rigors & night sweats General malaise Epitrochlear lymphadenopathy Illness onset Axillary lymphadenopathy Nodular lymphangitis ( Sporotrichoid like )? Mycobacterial, fungal, parasitic or other unusual infection R axillary lymph node biopsy (tissue and aspirate) Cultures repeated: different media, extended incubation 6s rrna gene PCR and sequencing Begun on empirical treatment Rifabutin, Isoniazid, Ethambutol, Moxifloxacin Further diagnostic testing (Westmead) 6s rrna on axillary aspirate Tobin EH, Jih WW. Am Fam Physician 200;63: Cross ML et al. J Wildl Dis Jul;45(3):

3 3 primers targeting conserved area of the U, U3 and U5 regions of the 6S rrna gene, amplifying the intervening variable regions Sequences are merged where possible to create a construct spanning most of the ~500bp Achieved a 33 base pair amplicon GNCB small, most easily seen with hindsight! (from centrifuged aspirate in Thioglycolate broth) 3 undisclosed targets 3/3 Positive (2/3 = presumptive ID) 3

4 Control Patient serum Test Line Immunochromato -graphic qualitative detection method Total anti - Francisella tularensis antibodies POSITIVE 9 Recombinase A gene ubiquitous in bacteria, vital in homologous recombination and DNA repair Useful for speciation of some genera RESULT: 939/965 bp amplicon showed 99% homology with several tularensis ssp including holarctica, tularensis, mediasiatica and novicida Published primers (Huber B et al. Int J Syst Evol Microbiol. 200) 7 primer pairs, 2 of which were positive (RD and RD6) Size of RD amplicon used to subspeciate 629bp with subspecies holarctica 840bp with subspecies holarctica biovar japonica 325bp with subspecies tularensis Tasmanian isolate = 835bp by capillary fragment separation, most consistent with F. tularensis ssp holarctica bv. japonica 6S Results Rifabutin Hospital Admission Isoniazid Ethambutol Moxifloxacin Hospital Admission Doxycycline Moxifloxacin Gentamicin Doxycycline Moxifloxacin Remains well D47 6 months D56 D75 D86 D00 Fever, rigors & night sweats General malaise Epitrochlear lymphadenopathy Axillary lymphadenopathy 4

5 Grossly enlarged, irregular marginated, solid lymph node with slight increased vascularity. This is surrounded by extensive oedema within the fat. There is no evidence of a drainable collection. General M/C/S Serology Possum Bite Metronidazole Excisional biopsy Clinical Resolution Augmentin DF Ciprofloxacin D0 D0 D20 D28 D70 D5 D25 D56 General malaise / lassitude Axillary lymphadenopathy Inflammation at primary site Illness onset Erythema nodosum 5

6 Identified in 9 following an outbreak of bubonic plague in Ground Squirrels Tularaemia aka Rabbit Fever, Pahvant Valley fever, Deer fly fever, Lemming fever, Ohara s disease Endemic in North America, Europe and parts of Asia >300 species of mammals, birds, invertebrates and amphibians have been found naturally infected 3 Edward Francis Unpublished data courtesy of Andreas Sjödin, Swedish Defence Research Agency. Ulceroglandular Glandular Oculoglandular Oropharyngeal Typhoidal Pneumonic Organism innoculatedthrough the skin barrier Primary ulcer with regional lymphadenopathy Similar to ulceroglandular Lacks the ulcerated site of initial infection Results from direct inoculation of the eye Unilateral conjunctivitis, photophobia and discharge Results from ingestion of contaminated food or water Pharyngitis with regional lymphadenopathy Severe systemic symptoms but no obvious portal of infection Inhalation of aerosols contaminated with F. tularensis May also occur secondarily from haematogenous spread Type A tularaemia North America Lagomorphia (rabbits, hares) main donors and reservoir Ticks, tabanid flies reservoir & vectors Highly virulent Pneumonic / typhoidal presentation in up to 80% Potential biologic weapon SSBA Tier 2 KeimP et al. Ann N Y Acad Sci Jun;05: Other Type B Tularaemia Wider distribution Lagomorphia, Rodentia, Insectivores donors and reservoir Ticks, tabanid fies & mosquitoes reservoirs and vectors Associated with aquatic environments Less severe disease Rare human pathogen 9 case reports Immunosuppressed One Australian case F. philomiragia Rare human pathogen 9 case reports Saltwater exposure, CGD Single Australian case Whipp et al J Med Microbiol 2003 Vol 52 no KeimP et al. Ann N Y Acad Sci Jun;05:

7 Subspecies holarctica is genetically very monomorphic, suggesting common ancestors and recent expansion across the Northern hemisphere Historically, human cases have occurred in areas not previously associated with tularaemia following the importation of wildlife from affected areas For example, from 937 through 940, nearly 26,300 Western rabbits were released into Massachusetts with the subsequent development and persistence of tularaemia Belding DL et al. N Engl J Med. 94 Jun 224(26): KeimP et al. Ann N Y Acad Sci Jun;05: Location Year Cases Cause Comments Tuscany, Italy Central Spain Central Spain Kosovo Southern Sweden Contaminated village water system; infected hare suspected source Only two prior cases previously reported; associated with importation of hares for hunting purposes Infected hares Only one case previously documented in Spain; outbreak a/w hare hunting Contaminated water and crayfish 327 Rodent-contaminated food and water Primarily mosquito bites Site far removed from 997 epidemic; sewage plant suspected as contamination source First outbreak of tularemia in Kosovo; associated with postwar environmental conditions Widespread outbreak in a geographic area where tularemia was previously rare Case : Feb -May 20 Notification to Public Health Possible case of Tularaemia (PHLN - Suggestive Criteria ) GP s alerted, records reviewed, DPIWE informed, media release Case 2: September 20 Task force convened Public Health, ID/Micro, DPIWE, political minders and spin doctors Further media releases Safe animal handling, water safety Pilot investigation Pilot investigation - November 20 5 km AOI, 6 DPIWE staff. Road kill, off road morbidity / mortality, targeted Ringtail Possum surveillance (dreys, faeces) Species Sample type Number of samples Ringtail possum Pseudocheirus Faeces 26 peregrinus Drey contents Tasmanian pademelon Tasmanian devil Brushtail possum Thylogale billardierii Carcass Ectoparasites Faeces Serum Sarcophilus harrisii Trichosurus vulpecula Carcass Faeces Carcass Ectoparasites Faeces Cat Felis catus Carcass

8 Pilot Investigation No positive cultures Further active surveillance a significant logistical and resource investment 2% of reservoir infected = need to sample 300 Ringtail Possums Ongoing passive surveillance GP S, hospitals, vets, wildlife carers Considering other options Sero-survey (? Human? Wildlife) All suggestions / assistance welcome!!! alistair.mcgregor@dhhs.tas.gov.au Royal Hobart Hospital Dr Justin Jackson Dr Chong Ong Dr Alison Ratcliff Dr Louise Cooley Westmead -ICPMR Dr Vitali Sintchenko Mitchell Brown Jimmy Ng Trang Nguyen Dr Neisha Jeoffreys Greg James Marion Yuen 45 8