65 y/o M with a history of Diabetes and Coronary Artery disease, but in his usual state of health presented with a five day history of malaise, productive cough, shortness of breath, fever, chills and rigor. Initial presentation and diagnostic studies were consistent with multi-lobar pneumonia and acute on chronic renal failure but patient quickly decompensated with acute hypoxic respiratory failure and worsening kidney function, requiring transfer to medical ICU with subsequent intubation for hypoxia. Patient’s renal failure continued to worsen with peak BUN/Cr of 102/4.5. Patient was subsequently placed on intermittent CRRT dialysis by nephrology. Further history from patient’s family revealed ‘multiple wild rabbits’ on patient’s property located in a rural part of Texas and that patient spent considerable time mowing the tall grass with his new lawn mower. It was suspected that patient’s sepsis and renal failure was from a suspected etiology of zoonosis. Blood cultures and sputum culture initially showed pleomorphic gram-negative rods that later speciated to Francisella tularensis. Patient was initiated on Ciprofloxacin 400 mg IV q12h which was the second line treatment, as patient’s renal failure precluded the use of aminoglycosides. Patient was successfully extubated, treated for four weeks with IV antibiotics and discharged home with complete resolution of symptoms at outpatient follow-up.
Discussion:
Tularemia is the zoonotic infection caused by Francisella tularensis, an aerobic and fastidious gram-negative bacterium. Clinical manifestations can range from non-specific symptoms of fevers, chills and malaise to septic shock/death. Of the six sub-types of Tularemia, pneumonic tularemia is a prevalent form. About 100 cases are reported yearly in the US and most cases occur in the south-central United States. Acute renal failure has been a rare, uniformly fatal complication of infection with Francisella tularensis. The literature suggests that “acute tubular necrosis, interstitial nephritis, or glomerulonephritis may be responsible for this syndrome”. The last time a case of acute renal failure associated with Tuleremia was reported in medicine literature was back in 1983.
Conclusions:
The diagnosis of tularemia requires a high index of suspicion based on the clinical presentation and history taking. Hospitalists encounter community acquired pneumonia syndromes and acute renal failure on a daily basis, but as demonstrated in this case, history taking and connecting the dots between key information such as “wild rabbits”, “aerosolized by lawn mower”, “acute renal failure” and “respiratory failure” is crucial for diagnosis. Early recognition of this rare but potentially fatal illness can lead to expedited diagnosis and potentially curative treatment.