Case Presentation: A 60-year-old female presented to the emergency department with a chief complaint of dyspnea, fevers, and malaise that had worsened over two days. She was found to be in acute hypoxic respiratory failure, requiring high levels of supplemental oxygen. Lab studies revealed leukocytosis, transaminitis, mild thrombocytopenia, and nephrotic-range proteinuria. She was admitted and treated for possible community-acquired pneumonia. Lung CT with IV contrast demonstrated pleural thickening, hilar lymphadenopathy, and various nodules. Due to worsening hypoxia, the patient was subsequently transferred to a tertiary care center for a higher level of care. Given the concomitant nephrotic-range proteinuria and findings on lung CT, concern was high for potential vasculitis versus sepsis; high-dose IV steroids and broad-spectrum antibiotics were initiated. After five days, blood cultures turned positive for Francisella tularensis. Upon further questioning, it was uncovered that the patient lived in a rural area and over the past few weeks she had been clearing and chopping brush. She denied tick bites, but did have rabbit wire surrounding blueberry bushes that she had cut her fingers on a few weeks prior to hospitalization. Antibiotics were narrowed to Gentamicin and IV steroids were tapered. The patient’s oxygenation dramatically improved with proper treatment. She completed nine days of IV Gentamicin and was discharged on an additional two-week course of oral Doxycycline.

Discussion: Francisella tularensis is an aerobic, slow growing, fastidious, gram-negative coccobacillus with an average incubation period of three to five days. Due to slow growth, diagnosis and proper treatment can often be delayed. Tularemia has traditionally been more prevalent in the south-central United States but has since shifted northward with climate change. The most commonly recognized form of Tularemia has traditionally been ulceroglandular, however, since 2015 an increase in number of Pneumonic Tularemia cases has been seen across the mid-west. The most commonly recognized mode of transmission is tick-borne, but transmission may also be airborne or due to exposure to infected animals and contaminated materials. Symptoms are often as ambiguous as fever, malaise, headache, and myalgias. Not only can Tularemia affect the lungs, but it can also lead to further complications such as sepsis, renal failure, rhabdomyolysis, hepatitis, and ultimately demise.

Conclusions: This case demonstrates the importance of keeping zoonotic infections, such as Tularemia, as part of a differential diagnosis given their changing geographic distribution, ambiguous presentation and potential severity. Additionally, given Tularemia’s possible airborne transmission, it poses a significant threat to healthcare workers the longer it goes undiagnosed. Recognition of Tularemia in a timely manner is crucial in avoiding further complications in hospitalized patients as well as decreasing transmission risk to healthcare workers.