Tularemia is an uncommon cause of acute lymphadenitis in outpatients in the pediatric age group and often is omitted from the differential diagnosis. During a four year period, we have diagnosed and treated 10 children who presented with lymphadenitis in an ambulatory setting in whom the diagnosis of tularemia was confirmed. We describe the clinical findings and outcome.

Between April 1993 and June 1996, ten children from rural South Dakota were diagnosed with lymphadenitis due to infection with Francisella tularensis. The age range at presentation was 10 months to 16 years; the mean was 5.7 years. During this period, only one adult (30 yr old male) from this population was diagnosed with tularemia. Although half of the patients presented during the spring and early summer months, patients were diagnosed during the seven months between April and October. Four of the ten (40%) had a documented tick exposure; none of the ten children had a known exposure to rabbits.

Eight of 10 patients presented with fever; one of the ten had a maximum temperature of 105° F. All patients had lymphadenopathy in the posterior or anterior cervical lymph nodes; in the majority the lymphadenitis was unilateral. Of interest, 2 individuals had supraclavicular lymphadenitis. None presented with hepatomegaly or splenomegaly. No patient had evidence of pneumonitis, either clinically or by thoracic roentgenogram.

The diagnosis of tularemia was confirmed serologically in nine of the ten children. The titers ranged from 1:160 to 1:2560. The organism was grown from submitted specimens (lymph node biopsy) from two of the ten children.

Seven of the patients underwent incision and drainage of the suppurative lymph node(s). Most (7) of the patients were treated with aminoglycosides; streptomycin was used in only two. Despite adequate antibiotic therapy, one of the ten relapsed and ultimately required 2 seven day courses of intravenous gentamicin and a subsequent 10 day course of streptomycin.

Tularemia is not rare in a rural ambulatory setting. Tularemia is an endemic disease. Contrary to commonly held beliefs, the disease most often manifests itself as lymphadenitis in children rather than the more fulminant systemic disease. This form of the infection is transmitted by tick exposure, rather than exposure to rabbits.