Tularemia is an unusual disease caused by the gram-negative coccobacillus Francisella tularensis. The clinical features of the disease depend on the route of inoculation. Ulceroglandular and typhoidal forms have been recognized as occurring in tularemia, however primary or secondary pneumonic infections have also been reported. Symptoms, laboratory markers and radiological features are non-specific in tularemic pneumonia. Diagnosis is made on clinical grounds and evidence of elevated agglutinating antibodies to F. tularensis (> 1:128). We report a case of primary tularemic pneumonia presenting with pulmonary infiltrates and necrotizing mediastinal and hilar lymph nodes in an otherwise healthy subject from a non-endemic area. Diagnosis of tularemia was obtained serologically, and antibiotic therapy with doxycycline and streptomycin resolved symptoms and radiological abnormalities. We suggest that tularemia should be considered in the differential diagnosis of pneumonia with mediastinal and/or hilar lymphadenopathy.

This is a case report describing an injury ± sustained by a 25-year-old man during a car accident, and characterized by fracture dislocation of the spine at the level of C7 and T4 accompanied by pulmonary contusion. He had an incomplete spinal cord lesion at the level of C7 and a complete lesion at the level of T4 (T4 ASIA A). Imaging of the spine showed three column fractures with ventral spinal cord compression at both levels. Discussants of this case comment on the concept of acute treatment of severe double spinal cord injuries, and present their chosen way of management in this particular case. Spinal Cord (2001) 39, 492 ± 497Keywords: double injuries of the spine; incomplete spinal cord injury; complete spinal cord injury; primary treatment; neurological recovery Case presentationA 25-year-old male was admitted after a car accident. He su ered severe low cervical and upper thoracic spine injuries. On admission the neurologic examination revealed complete motor function loss from the level of C7, incomplete sensory loss from C7 to T3, and complete loss of both motor and sensory functions from the level of T4 with over¯ow incontinence (Frankel B from C7 to T3, and Frankel A from T4, ASIA motor score 10, sensory score 52). Megadose methylprednisolone treatment was administered according to NASCIS 3, starting 1 h after injury. Xray, CT scan and MRI showed three column fractures both in the levels of C7 and T4 with ventral encroachment and severe medullary compression at both levels. The most informative MRI pictures revealed contusion and traumatic oedema of the spinal cord at both of the injured levels ( Figure 1). The chest X-ray showed mild pulmonary contusion. He had no other injuries. His primary laboratory parameters were normal.

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