Case Presentation: A 49 year old man with a medical history significant for hypertension and hyperlipidemia presented to the ER with worsening shortness of breath, cough and malaise. His initial work-up revealed normal lab values and no acute abnormality on Chest X-ray (CXR). Two days later he presented with unrelenting fever and worsening respiratory symptoms. His physical examination showed acute respiratory distress, temp of 102.9, tachypneic and decreased breath sounds bilaterally. CXR showed bilateral infiltrates. Laboratory exam revealed leukocytosis of 18,000 with 3 % bands, hyperbilirubinemia of 1.9 mg/dL with transaminitis and sodium of 128 mmol/L . Antibiotic treatment with ampicillin/sulbactam was started. His respiratory status worsened through the course of the day requiring intubation and vasopressor support. Antibiotics were empirically changed to linezolid, piperacillin/tazobactam and levofloxacin. Legionella cultures were obtained. The patient continued to be hypoxic despite maximal respiratory support and placed on Extra Corporeal Membrane Oxygenation. He developed acute renal failure and continuous venovenous diafiltration was initiated. Cultures from legionella media came back positive for Francisella tularensis and was started on gentamicin. Despite aggressive antibiotic and supportive therapy, the patient’s condition deteriorated and he succumbed to the illness. On retrospective history review, it was revealed that patient was a squirrel trapper. Public health department was notified. 

Discussion: Tularemia is a zoonotic infection caused by Francisella tularensis, a gram negative coccobacillus. The presentation may range from asymptomatic illness to septic shock and death. Approximately 24 % of all tularemia cases constitute pulmonary disease. Multiorgan dysfunction can occur in view of its virulent nature. A detailed history helps in early diagnosis and treatment. This organism has gained significant research interest as it is a potential agent for biological warfare. Described below is a case of tularemia with acute worsening of pulmonic disease. 

Conclusions: First identified in 1912 at Tulare county in California, Tularemia is also known as O’hara’s disease and rabbit fever. Human infection occurs following contact with infected animals. Since it is a potentially serious and life threatening disease which is treatable, early suspicion and appropriate testing is required. Diagnosis is made by serologic testing or culture. Pulmonary tularemia has a highly variable clinical as well as radiological presentation and hence, diagnosis can be very difficult. First line agents for treatment include aminoglycoside antibiotics such as gentamicin.