{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,9]],"date-time":"2026-10-09T04:50:23Z","timestamp":1791521423872,"version":"4.3.4"},"reference-count":9,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,10,9]],"date-time":"2026-10-09T00:00:00Z","timestamp":1791504000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Med."],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>\n                      Respiratory tularemia is a rare but potentially serious manifestation of\n                      <jats:italic>Francisella tularensis<\/jats:italic>\n                      infection. We report a rare case of bacteremic respiratory tularemia complicated by refractory acute respiratory distress syndrome (ARDS) requiring veno-venous extracorporeal membrane oxygenation (VV-ECMO), highlighting the diagnostic challenges and therapeutic implications of this uncommon presentation.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Case presentation<\/jats:title>\n                    <jats:p>\n                      A 78-year-old man developed severe pneumonia following river water aspiration after a bicycle accident. After transient initial improvement, he experienced progressive respiratory deterioration despite broad-spectrum antimicrobial treatment, ultimately developing refractory ARDS requiring invasive mechanical ventilation, prone positioning and VV-ECMO. Three consecutive sets of blood cultures revealed the presence of\n                      <jats:italic>Francisella tularensis,<\/jats:italic>\n                      whereas bronchoalveolar lavage (BAL) cultures remained negative. No extrapulmonary manifestations of tularemia were identified. Targeted antimicrobial therapy with ciprofloxacin and gentamicin was initiated but failed to prevent a fatal outcome.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>\n                      Respiratory tularemia should be considered in patients with severe pneumonia following environmental exposure, particularly when respiratory status deteriorates despite broad-spectrum \u03b2-lactam therapy. Repeated blood cultures may establish the diagnosis despite negative BAL cultures. Early recognition and prompt initiation of effective antimicrobial therapy are essential, as \u03b2-lactam antibiotics are clinically ineffective against\n                      <jats:italic>F. tularensis<\/jats:italic>\n                      . This case also illustrates the potential severity of respiratory tularemia, which may progress to refractory ARDS requiring VV-ECMO.\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fmed.2026.1965100","type":"journal-article","created":{"date-parts":[[2026,10,9]],"date-time":"2026-10-09T04:25:46Z","timestamp":1791519946000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Case Report: Bacteremic respiratory tularemia causing refractory ARDS requiring VV-ECMO"],"prefix":"10.3389","volume":"13","author":[{"given":"Cynthia","family":"Wenglinski","sequence":"first","affiliation":[{"name":"Department of Intensive Care Medicine, CHU Charleroi-Chimay (HUmani)","place":["Charleroi, Belgium"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fabrizio","family":"Buttafuoco","sequence":"additional","affiliation":[{"name":"Department of Infectious Diseases, CHU Charleroi-Chimay (HUmani)","place":["Charleroi, Belgium"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Micha\u00ebl","family":"Piagnerelli","sequence":"additional","affiliation":[{"name":"Department of Intensive Care Medicine, CHU Charleroi-Chimay (HUmani)","place":["Charleroi, Belgium"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,10,9]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"1","DOI":"10.15585\/mmwr.rr7402a1","article-title":"Tularemia antimicrobial treatment and prophylaxis: cDC recommendations for naturally acquired infections and bioterrorism response \u2014 united States, 2025","volume":"74","author":"Nelson","year":"2025","journal-title":"MMWR Recomm Rep"},{"key":"B2","doi-asserted-by":"publisher","first-page":"S15","DOI":"10.1093\/cid\/ciad736","article-title":"Systematic review: clinical features, antimicrobial treatment, and outcomes of human tularemia, 1993\u20132023","volume":"78","author":"Nelson","year":"2024","journal-title":"Clin Infect Dis"},{"key":"B3","doi-asserted-by":"publisher","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":"B4","doi-asserted-by":"publisher","first-page":"678","DOI":"10.3201\/eid3104.240414","article-title":"Epidemiology of tularemia among humans and animals, baden-wuerttemberg, Germany, 2012\u20132022","volume":"31","author":"Nothdurfter","year":"2025","journal-title":"Emerg Infect Dis"},{"key":"B5","doi-asserted-by":"publisher","first-page":"S38","DOI":"10.1093\/cid\/ciad690","article-title":"Treatment outcome of severe respiratory type B tularemia using fluoroquinolones","volume":"78","author":"Widerstr\u00f6m","year":"2024","journal-title":"Clin Infect Dis"},{"key":"B6","doi-asserted-by":"publisher","first-page":"108350","DOI":"10.1016\/j.ijid.2025.108350","article-title":"Pulmonary tularemia: a diagnosis not to overlook","volume":"164","author":"Zaghdoudi","year":"2026","journal-title":"Int J Infect Dis"},{"key":"B7","doi-asserted-by":"publisher","first-page":"101882","DOI":"10.1016\/j.rmcr.2023.101882","article-title":"Francisella tularensis subsp. holarctica bacteraemia in an immunocompetent male","volume":"45","author":"Schepens","year":"2023","journal-title":"Respir Med Case Rep"},{"key":"B8","doi-asserted-by":"publisher","first-page":"e02180","DOI":"10.1016\/j.idcr.2024.e02180","article-title":"Tularemia-associated septic shock with pneumonia, lung abscesses, and pleural effusion leading to multiorgan failure: is francisella tularensis still a deadly pathogen in the antibiotic era? A case report","volume":"39","author":"Popio\u0142ek","year":"2024","journal-title":"IDCases"},{"key":"B9","doi-asserted-by":"publisher","first-page":"e272295","DOI":"10.1136\/bcr-2026-272295","article-title":"Severe pneumonic tularemia following inhalational exposure with acute respiratory distress syndrome and multiorgan failure","volume":"19","author":"Thomas","year":"2026","journal-title":"BMJ Case Rep"}],"container-title":["Frontiers in Medicine"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fmed.2026.1965100\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,9]],"date-time":"2026-10-09T04:25:47Z","timestamp":1791519947000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fmed.2026.1965100\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,10,9]]},"references-count":9,"alternative-id":["10.3389\/fmed.2026.1965100"],"URL":"https:\/\/doi.org\/10.3389\/fmed.2026.1965100","relation":{},"ISSN":["2296-858X"],"issn-type":[{"value":"2296-858X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,10,9]]},"article-number":"1965100"}}