A Rare Case of Tularemia Complicated by Rhabdomyolysis with a Successful Outcome

Abstract

We present a case of tularemia complicated by rhabdomyolysis in a 43-year-old male who presented with fever, swelling, and pain of the right groin and a history of a week-old tick bite. Empirical parenteral amoxicillin/clavulanic acid treatment was initiated. Suspecting tularemia, parenteral gentamycin was added. Later, the patient started to complain of muscle pain, weakness, and difficulties in breathing and walking. Heightened levels of creatine kinase and myoglobin concentration (42,670 IU/L and >12,000 μg/L, respectively) were found. Due to rhabdomyolysis, large amounts of intravenous fluid therapy were initiated to prevent kidney damage, continuing intravenous antibiotic therapy. Francisella tularensis IgG in serum was found to be positive only on the sixteenth day of hospitalization. Upon discharge, the laboratory analyses returned to normal levels, and the patient was in good condition. The successful outcome could be associated with the early appropriate therapy of tularemia and its rare complication of rhabdomyolysis.

Tularemia treatment: experimental and clinical data

“…Table 6 summarizes data from tularemia case series with a predominance of the UG or GL forms. Many other sporadic UG or GL tularemia cases have been reported in several countries but with similar findings than those reported in case series ( Pérez-Castrillón et al, 2001 ; Jackson et al, 2012 ; Sobolewska-Pilarczyk et al, 2014 ; Boone et al, 2015 ; Formińska et al, 2015 ; Calin et al, 2017 ; Pekova et al, 2017 ; Whitten et al, 2017 ; Haulrig et al, 2020 ; Kubiliute et al, 2021 ). The UG and GL forms are predominant worldwide, except in some countries such as Turkey (see below).…”

“…There are copious data available to confirm that the beta-lactams, most macrolides, lincosamides, synergistins, and first-line antituberculosis drugs (except streptomycin) are almost ineffective in tularemia patients ( Arikan et al, 2003 ; Sencan et al, 2009 ; Willke et al, 2009 ; Cağlı et al, 2011 ; Mahy et al, 2011 ; Maurin et al, 2011 ; Altuntas et al, 2012 ; Jackson et al, 2012 ; Erdem et al, 2014 ; Sobolewska-Pilarczyk et al, 2014 ; Boone et al, 2015 ; Formińska et al, 2015 ; Pekova et al, 2017 ; Whitten et al, 2017 ; Darmon-Curti et al, 2020 ; Haulrig et al, 2020 ; Kubiliute et al, 2021 ). Failure of treatment with beta-lactams may even suggest a diagnosis of tularemia in a compatible clinical and epidemiological context.…”

“…Beta-lactams (penicillin, amoxicillin, amoxicillin-clavulanate, cefuroxime, cefotaxime, ceftriaxone), macrolides (clarithromycin, clindamycin), and antituberculosis drugs often given as empirical treatments in UG and GL tularemia patients were ineffective ( Maurin et al, 2011 ; Jackson et al, 2012 ; Sobolewska-Pilarczyk et al, 2014 ; Boone et al, 2015 ; Formińska et al, 2015 ; Pekova et al, 2017 ; Whitten et al, 2017 ; Haulrig et al, 2020 ; Kubiliute et al, 2021 ). Overall, gentamicin, ciprofloxacin (as well as levofloxacin and moxifloxacin) and doxycycline were the most successful treatments.…”

“…However, severe cases requiring hospitalization are more likely to be reported than milder cases and thus might be overestimated in the literature. In some patients, complications occurred while under appropriate antibiotic therapy, including continued enlargement of the infected lymph nodes, involvement of new lymph nodes, regional and systemic complications ( Jackson et al, 2012 ; Kızıl et al, 2012 ; Weber et al, 2012 ; Formińska et al, 2015 ; Calin et al, 2017 ; Haulrig et al, 2020 ; Kubiliute et al, 2021 ). A few patients with UG or GL forms died (2/418, 0.48% for the above sporadic cases and case series).…”

Tularemia Presenting Solely with Cervical Lymphadenopathy and Fever

“…Furthermore, patients may present with myoglobinuria as well as pyuria, which may be falsely diagnosed as a urinary tract infection. Rhabdomyolysis with elevated serum creatinine kinase levels has also been described in some patients [ 15 , 18 , 19 ].…”