{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,5]],"date-time":"2026-02-05T08:16:10Z","timestamp":1770279370494,"version":"3.49.0"},"reference-count":28,"publisher":"Oxford University Press (OUP)","issue":"1","license":[{"start":{"date-parts":[[2017,2,15]],"date-time":"2017-02-15T00:00:00Z","timestamp":1487116800000},"content-version":"vor","delay-in-days":45,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0"}],"funder":[{"name":"Arkansas Department of Health"},{"DOI":"10.13039\/100000030","name":"Centers for Disease Control and Prevention","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100000030","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2017,1,1]]},"abstract":"<jats:title>Abstract<\/jats:title>\n               <jats:sec>\n                  <jats:title>Background<\/jats:title>\n                  <jats:p>Francisella tularensis, although naturally occurring in Arkansas, is also a Tier 1 select agent and potential bioterrorism threat. As such, tularemia is nationally notifiable and mandatorily reported to the Arkansas Department of Health. We examined demographic and clinical characteristics among reported cases and outcomes to improve understanding of the epidemiology of tularemia in Arkansas.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Methods<\/jats:title>\n                  <jats:p>Surveillance records on all tularemia cases investigated during 2009\u20132013 were reviewed.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>The analytic dataset was assembled from 284 tularemia reports, yielding 138 probable and confirmed tularemia cases during 2009\u20132013. Arthropod bite was identified in 77% of cases. Of 7 recognized tularemia manifestations, the typhoidal form was reported in 47% of cases, approximately double the proportion of the more classic manifestation, lymphadenopathy. Overall, 41% of patients were hospitalized; 3% died. The typhoidal form appeared to be more severe, accounting for the majority of sepsis and meningitis cases, hospitalizations, and deaths. Among patients with available antibiotic data, 88% received doxycycline and 12% received gentamicin.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusions<\/jats:title>\n                  <jats:p>Contrary to expectation, lymphadenopathy was not the most common manifestation observed in our registry. Instead, our patients were more likely to report only generalized typhoidal symptoms. Using lymphadenopathy as a primary symptom to initiate tularemia testing may be an insensitive diagnostic strategy and result in unrecognized cases. In endemic areas such as Arkansas, suspicion of tularemia should be high, especially during tick season. Outreach to clinicians describing the full range of presenting symptoms may help address misperceptions about tularemia.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1093\/ofid\/ofx027","type":"journal-article","created":{"date-parts":[[2017,2,15]],"date-time":"2017-02-15T12:33:53Z","timestamp":1487162033000},"source":"Crossref","is-referenced-by-count":15,"title":["Variation in Tularemia Clinical Manifestations\u2014Arkansas, 2009\u20132013"],"prefix":"10.1093","volume":"4","author":[{"given":"Laura K.","family":"Lester Rothfeldt","sequence":"first","affiliation":[{"name":"Epidemic Intelligence Service, Division of Scientific and Professional Development, Centers for Disease Control and Prevention, Atlanta, Georgia"},{"name":"Arkansas Department of Health, Little Rock"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Richard F.","family":"Jacobs","sequence":"additional","affiliation":[{"name":"Arkansas Children\u2019s Hospital, Little Rock; and"},{"name":"University of Arkansas for Medical Sciences, Little Rock"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"J. Gary","family":"Wheeler","sequence":"additional","affiliation":[{"name":"Arkansas Department of Health, Little Rock"},{"name":"Arkansas Children\u2019s Hospital, Little Rock; and"},{"name":"University of Arkansas for Medical Sciences, Little Rock"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Susan","family":"Weinstein","sequence":"additional","affiliation":[{"name":"Arkansas Department of Health, Little Rock"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Dirk T.","family":"Haselow","sequence":"additional","affiliation":[{"name":"Arkansas Department of Health, Little Rock"},{"name":"Arkansas Children\u2019s Hospital, Little Rock; and"},{"name":"University of Arkansas for Medical Sciences, Little Rock"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"286","published-online":{"date-parts":[[2017,2,15]]},"reference":[{"key":"2020081005172130500_CIT0001","doi-asserted-by":"crossref","first-page":"487","DOI":"10.1097\/00006454-198311000-00019","article-title":"Tularemia in children","volume":"2","author":"Jacobs","year":"1983","journal-title":"Pediatr Infect Dis"},{"key":"2020081005172130500_CIT0002","doi-asserted-by":"crossref","first-page":"332","DOI":"10.1016\/j.vetmic.2009.07.017","article-title":"Tularemia","volume":"140","author":"Foley","year":"2010","journal-title":"Vet Microbiol"},{"key":"2020081005172130500_CIT0003","first-page":"2927","article-title":"Francisella tularensis (Tularemia)","volume-title":"Principles and Practices of Infectious Diseases","author":"Penn","year":"2010","edition":"7th edition"},{"key":"2020081005172130500_CIT0004","doi-asserted-by":"crossref","first-page":"289","DOI":"10.1016\/j.idc.2006.03.002","article-title":"Tularemia: current epidemiology and disease management","volume":"20","author":"Eliasson","year":"2006","journal-title":"Infect Dis Clin North Am"},{"key":"2020081005172130500_CIT0005","doi-asserted-by":"crossref","first-page":"631","DOI":"10.1128\/CMR.15.4.631-646.2002","article-title":"Tularemia","volume":"15","author":"Ellis","year":"2002","journal-title":"Clin Microbiol Rev"},{"key":"2020081005172130500_CIT0006","doi-asserted-by":"crossref","first-page":"863","DOI":"10.1086\/597261","article-title":"Molecular epidemiology of Francisella tularensis in the United States","volume":"48","author":"Kugeler","year":"2009","journal-title":"Clin Infect Dis"},{"key":"2020081005172130500_CIT0007","doi-asserted-by":"crossref","first-page":"1601","DOI":"10.1056\/NEJMoa011374","article-title":"An outbreak of primary pneumonic tularemia on Martha\u2019s Vineyard","volume":"345","author":"Feldman","year":"2001","journal-title":"N Engl J Med"},{"key":"2020081005172130500_CIT0008","doi-asserted-by":"crossref","first-page":"350","DOI":"10.3201\/eid0903.020462","article-title":"Tularemia on Martha\u2019s Vineyard: seroprevalence and occupational risk","volume":"9","author":"Feldman","year":"2003","journal-title":"Emerg Infect Dis"},{"key":"2020081005172130500_CIT0009","doi-asserted-by":"crossref","first-page":"293","DOI":"10.1111\/j.1529-8019.2009.01244.x","article-title":"Diagnosis and treatment of tick infestation and tick-borne diseases with cutaneous manifestations","volume":"22","author":"Dana","year":"2009","journal-title":"Dermatol Ther"},{"key":"2020081005172130500_CIT0010","first-page":"1657","article-title":"Tularemia","volume-title":"Feigin and Cherry\u2019s Textbook of Pediatric Infectious Diseases","author":"Schutze","year":"2014"},{"key":"2020081005172130500_CIT0011","first-page":"268","article-title":"Tularemia","volume-title":"Understanding Zoonotic Diseases","author":"Romich","year":"2008"},{"key":"2020081005172130500_CIT0012","doi-asserted-by":"crossref","first-page":"43","DOI":"10.1016\/j.idc.2009.10.012","article-title":"Tularemia pneumonia","volume":"24","author":"Thomas","year":"2010","journal-title":"Infect Dis Clin North Am"},{"key":"2020081005172130500_CIT0013","doi-asserted-by":"crossref","first-page":"2763","DOI":"10.1001\/jama.285.21.2763","article-title":"Tularemia as a biological weapon: medical and public health management","volume":"285","author":"Dennis","year":"2001","journal-title":"JAMA"},{"key":"2020081005172130500_CIT0014","first-page":"963","article-title":"Tularemia\u2014United States, 2001\u20132010","volume":"62","author":"Nelson","year":"2013","journal-title":"MMWR Morbid Mortal Wkly Rep"},{"key":"2020081005172130500_CIT0015","first-page":"61083","article-title":"42 CFR Part 73: possession, use, and transfer of select agents and toxins; biennial review, final rule","volume":"77","year":"2012","journal-title":"Federal Register"},{"key":"2020081005172130500_CIT0016","volume-title":"Tularemia Case Reporting Form","author":"Centers for Disease Control and Prevention","year":"2006"},{"key":"2020081005172130500_CIT0017","volume-title":"Tularemia (Francisella tularensis) 1999 case definition","author":"Centers for Disease Control and Prevention"},{"key":"2020081005172130500_CIT0018","volume-title":"The physician\u2019s guide to laboratory test selection and interpretation. Francisella tularensis\u2014tularemia","author":"ARUP Consult"},{"key":"2020081005172130500_CIT0019","volume-title":"Laboratory test directory. Francisella tularensis antibodies, IgG and IgM","author":"ARUP Laboratories"},{"key":"2020081005172130500_CIT0020","volume-title":"Test ID: FRANC Francisella tularensis antibody","author":"Mayo Clinic Mayo Medical Laboratories"},{"key":"2020081005172130500_CIT0021","volume-title":"Reported tularemia cases\u2014United States, 2004\u20132013","author":"Centers for Disease Control and Prevention"},{"key":"2020081005172130500_CIT0022","doi-asserted-by":"crossref","first-page":"1283","DOI":"10.1093\/cid\/cis706","article-title":"Clinical recognition and management of tularemia in Missouri: a retrospective records review of 121 cases","volume":"55","author":"Weber","year":"2012","journal-title":"Clin Infect Dis"},{"key":"2020081005172130500_CIT0023","doi-asserted-by":"crossref","first-page":"1253","DOI":"10.1056\/NEJM196906052802301","article-title":"Tularemia epidemic: Vermont, 1968","volume":"23","author":"Young","year":"1969","journal-title":"N Engl J Med"},{"key":"2020081005172130500_CIT0024","doi-asserted-by":"crossref","first-page":"489","DOI":"10.1016\/j.idc.2008.03.004","article-title":"Tularemia","volume":"22","author":"Nigrovic","year":"2008","journal-title":"Infect Dis Clin North Am"},{"key":"2020081005172130500_CIT0025","first-page":"39","article-title":"Treatment of tularemia, including pulmonary tularemia, with gentamicin","volume":"121","author":"Mason","year":"1980","journal-title":"Am Rev Respir Dis"},{"key":"2020081005172130500_CIT0026","volume-title":"Rocky Mountain Spotted Fever (RMSF) Statistics and Epidemiology","author":"Centers for Disease Control and Prevention"},{"key":"2020081005172130500_CIT0027","volume-title":"Ehrlichiosis Statistics and Epidemiology","author":"Centers for Disease Control and Prevention"},{"key":"2020081005172130500_CIT0028","volume-title":"Anaplasmosis Statistics and Epidemiology","author":"Centers for Disease Control and Prevention"}],"container-title":["Open Forum Infectious Diseases"],"original-title":[],"language":"en","link":[{"URL":"http:\/\/academic.oup.com\/ofid\/article-pdf\/4\/1\/ofx027\/33622689\/ofx027.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"http:\/\/academic.oup.com\/ofid\/article-pdf\/4\/1\/ofx027\/33622689\/ofx027.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2020,8,10]],"date-time":"2020-08-10T09:18:12Z","timestamp":1597051092000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/ofid\/article\/doi\/10.1093\/ofid\/ofx027\/2996752"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2017,1,1]]},"references-count":28,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2017,1,1]]}},"URL":"https:\/\/doi.org\/10.1093\/ofid\/ofx027","relation":{},"ISSN":["2328-8957"],"issn-type":[{"value":"2328-8957","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2017]]},"published":{"date-parts":[[2017,1,1]]},"article-number":"ofx027"}}