Most authorities still classify tularemia into six clinical forms that loosely correlate with the usual route of exposure and presenting complaints-ulceroglandular, glandular, oculoglandular, pharyngeal, typhoidal, and pneumonic. The size of the inoculum and host response undoubtedly plays some role in the clinical presentation. However some authorities prefer to lump the six categories into two basic groups: ulceroglandular, which accounts for about three fourths of the cases (and includes all presentations with skin or mucous membrane lesions or lymph nodes ≥ 1cm) and typhoidal, which accounts for the remaining quarter.
Most patients have fever; headache, chills, cough, chest pain, sore throat, vomiting, diarrhea, anorexia, and abdominal pain are also common. Stiff neck and back pain may occur. A rash may occur in up to one third of patients and can take almost any form-maculopapular, vesiculopapular, erythema nodosum, erythema multiforme, and urticaria.
Patients with oculoglandular tularemia present with painful, often purulent, conjunctivitis, which is associated with lymphadenopathy of the head and neck that may be preceded by photophobia and tearing.
Patients with pharyngeal tularemia, have severe sore throat unresponsive to penicillin; and those with classic typhoidal tularemia, have the nonspecific symptoms described above with no localizing symptoms. Skin lesions (ulceroglandular), may precede, follow, or occur concurrent to lymphadenopathy, and usually progress from a painful papule to a pustule that ulcerates with a raised border around a crater. Lymphadenopathy (glandular) may occur without skin lesions but with systemic symptoms.
Pneumonic tularemia can be either primary or secondary; secondary pneumonia is particularly likely to accompany primary pharyngeal or classic typhoidal (ie, no obvious focus). Patients with pneumonic tularemia usually have a dry nonproductive cough, dyspnea, pleuritic chest pain, and fever. Physical examination may be nonspecific or reveal rales, a friction rub, or signs of consolidation or effusion.
Symptoms common to all forms include fever; headache, chills, cough, chest pain, sore throat, vomiting, diarrhea, anorexia, and abdominal pain, with stiff neck and back pain occurring less frequently. A rash occurs in about one third of patients varying from maculopapular, vesiculopapular, erythema nodosum, erythema multiforme, to urticaria.