{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,9]],"date-time":"2026-10-09T16:25:31Z","timestamp":1791563131413,"version":"4.3.4"},"reference-count":24,"publisher":"BMJ","issue":"6","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Case Rep"],"accepted":{"date-parts":[[2026,6,1]]},"published-print":{"date-parts":[[2026,6]]},"abstract":"<jats:p>\n                    A man in his early 70s presented with septic shock and severe ARDS, likely after aerosolising\n                    <jats:italic>Francisella tularensis<\/jats:italic>\n                    . Initial empirical treatment for community-acquired pneumonia with ceftriaxone failed, resulting in clinical deterioration with stage 3 acute kidney injury requiring dialysis and necrotising pneumonia. After pneumonic tularaemia was identified, antimicrobial therapy was transitioned to renally dosed levofloxacin, along with aggressive ICU support including prone positioning and tube thoracostomy. The patient ultimately made a full recovery, returning to his functional baseline one month after discharge.\n                  <\/jats:p>\n                  <jats:p>This case underscores the importance of eliciting environmental exposures in patients with severe, culture-negative pneumonia unresponsive to beta-lactams, as this should prompt consideration of inhalational tularaemia. It also highlights how pathogen-induced cytokine storm can drive catastrophic multiorgan failure and supports fluoroquinolones as a safe and effective first-line alternative to aminoglycosides in the setting of renal failure.<\/jats:p>","DOI":"10.1136\/bcr-2026-272295","type":"journal-article","created":{"date-parts":[[2026,6,19]],"date-time":"2026-06-19T12:40:36Z","timestamp":1781872836000},"page":"e272295","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":1,"title":["Severe pneumonic tularemia following inhalational exposure with acute respiratory distress syndrome and multiorgan failure"],"prefix":"10.1136","volume":"19","author":[{"given":"Shavin S","family":"Thomas","sequence":"first","affiliation":[{"name":"Department of Internal Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joshua P","family":"Gillen","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nolan R","family":"Fox","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1465-8693","authenticated-orcid":false,"given":"Christopher O","family":"Eden","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,6,19]]},"reference":[{"key":"2026061905402936000_19.6.e272295.1","doi-asserted-by":"publisher","DOI":"10.1016\/j.idc.2009.10.012"},{"key":"2026061905402936000_19.6.e272295.2","article-title":"An Uncommon Presentation of Pulmonary Tularemia: A Case Report and Literature Review","volume":"14","author":"Roth","year":"2022","journal-title":"Cureus"},{"key":"2026061905402936000_19.6.e272295.3","doi-asserted-by":"publisher","DOI":"10.1196\/annals.1409.013"},{"key":"2026061905402936000_19.6.e272295.4","doi-asserted-by":"crossref","first-page":"127","DOI":"10.1016\/j.ccm.2016.11.006","article-title":"Postviral Complications","volume":"38","author":"Prasso","year":"2017","journal-title":"Clin Chest Med"},{"key":"2026061905402936000_19.6.e272295.5","doi-asserted-by":"publisher","DOI":"10.1001\/jama.285.21.2763"},{"key":"2026061905402936000_19.6.e272295.6","doi-asserted-by":"crossref","first-page":"25","DOI":"10.1016\/j.ejim.2025.03.013","article-title":"Tularemia for clinicians: An up-to-date review on epidemiology, diagnosis, prevention and treatment","volume":"135","author":"Antonello","year":"2025","journal-title":"Eur J Intern Med"},{"key":"2026061905402936000_19.6.e272295.7","doi-asserted-by":"publisher","DOI":"10.1001\/archinte.1996.00440170155017"},{"key":"2026061905402936000_19.6.e272295.8","doi-asserted-by":"crossref","DOI":"10.3389\/fmicb.2023.1348323","article-title":"Tularemia treatment: experimental and clinical data","volume":"14","author":"Maurin","year":"2023","journal-title":"Front Microbiol"},{"key":"2026061905402936000_19.6.e272295.9","doi-asserted-by":"crossref","first-page":"159","DOI":"10.1111\/zph.12114","article-title":"Hunting for tularaemia - a review of cases in North Carolina","volume":"62","author":"Rimawi","year":"2015","journal-title":"Zoonoses Public Health"},{"key":"2026061905402936000_19.6.e272295.10","doi-asserted-by":"publisher","DOI":"10.1016\/j.micpath.2011.03.007"},{"key":"2026061905402936000_19.6.e272295.11","doi-asserted-by":"publisher","DOI":"10.1354\/vp.08-VP-0302-T-AM"},{"key":"2026061905402936000_19.6.e272295.12","doi-asserted-by":"crossref","DOI":"10.1371\/journal.ppat.1005517","article-title":"An Immature Myeloid\/Myeloid-Suppressor Cell Response Associated with Necrotizing Inflammation Mediates Lethal Pulmonary Tularemia","volume":"12","author":"Periasamy","year":"2016","journal-title":"PLoS Pathog"},{"key":"2026061905402936000_19.6.e272295.13","doi-asserted-by":"publisher","DOI":"10.1001\/jama.1933.02740400034010"},{"key":"2026061905402936000_19.6.e272295.14","doi-asserted-by":"crossref","first-page":"103","DOI":"10.1378\/chest.16.1.103","article-title":"A case of fatal tularemic pneumonia with necropsy","volume":"16","author":"Crellin","year":"1949","journal-title":"Dis Chest"},{"key":"2026061905402936000_19.6.e272295.15","doi-asserted-by":"publisher","DOI":"10.1001\/archinte.1985.00360080109016"},{"key":"2026061905402936000_19.6.e272295.16","doi-asserted-by":"crossref","first-page":"1607","DOI":"10.1007\/s15010-024-02204-1","article-title":"Thoracic manifestations of tularaemia: a case series","volume":"52","author":"Vacca","year":"2024","journal-title":"Infection"},{"key":"2026061905402936000_19.6.e272295.17","doi-asserted-by":"crossref","DOI":"10.1016\/j.chest.2022.08.434","article-title":"Understanding the need for a broad differential diagnosis: a case of pneumonic tularemia","volume":"162","author":"Husna","year":"2022","journal-title":"Chest"},{"key":"2026061905402936000_19.6.e272295.18","doi-asserted-by":"crossref","unstructured":"Tamma PD , Heil EL , Justo JA , et al . Infectious diseases society of America 2024 guidance on the treatment of antimicrobial-resistant gram-negative infections. Clin Infect Dis 2024:ciae403. doi:10.1093\/cid\/ciae403","DOI":"10.1093\/cid\/ciae403"},{"key":"2026061905402936000_19.6.e272295.19","doi-asserted-by":"crossref","first-page":"S29","DOI":"10.1093\/cid\/ciad689","article-title":"Tularemia Clinical Manifestations, Antimicrobial Treatment, and Outcomes: An Analysis of US Surveillance Data, 2006-2021","volume":"78","author":"Wu","year":"2024","journal-title":"Clin Infect Dis"},{"key":"2026061905402936000_19.6.e272295.20","doi-asserted-by":"publisher","DOI":"10.15585\/mmwr.rr7401a1"},{"key":"2026061905402936000_19.6.e272295.21","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(21)00439-6"},{"key":"2026061905402936000_19.6.e272295.22","doi-asserted-by":"publisher","DOI":"10.1001\/jama.2017.21907"},{"key":"2026061905402936000_19.6.e272295.23","doi-asserted-by":"crossref","first-page":"1820","DOI":"10.1097\/CCM.0000000000003406","article-title":"Beyond Low Tidal Volume Ventilation: Treatment Adjuncts for Severe Respiratory Failure in Acute Respiratory Distress Syndrome","volume":"46","author":"Fielding-Singh","year":"2018","journal-title":"Crit Care Med"},{"key":"2026061905402936000_19.6.e272295.24","doi-asserted-by":"publisher","DOI":"10.1001\/jama.1932.27410700004010b"}],"container-title":["BMJ Case Reports"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bcr-2026-272295","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,19]],"date-time":"2026-06-19T12:40:39Z","timestamp":1781872839000},"score":1,"resource":{"primary":{"URL":"https:\/\/casereports.bmj.com\/lookup\/doi\/10.1136\/bcr-2026-272295"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,6]]},"references-count":24,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2026,6,19]]},"published-print":{"date-parts":[[2026,6]]}},"alternative-id":["10.1136\/bcr-2026-272295"],"URL":"https:\/\/doi.org\/10.1136\/bcr-2026-272295","relation":{},"ISSN":["1757-790X"],"issn-type":[{"value":"1757-790X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6]]}}}