A case of tularemia after an endurance run in a non-endemic region.

A 37-year-old man with past history of psoriasis presented with a 5-day history of fever up to 40 C, chills, hypersudation, and painful swelling in the subinguinal area of the right thigh, followed by a non-productive cough the next day. He self-medicated with paracetamol 10 g/day. Some days before, in December, he had done an endurance run in a forest around Paris. Physical examination revealed a 25 9 15-mm inflammatory and painful swelling corresponding to an inguinal adenopathy with several other small satellite adenopathies upon ultrasound examination, and a small ulceropapular lesion towards the internal ankle of the right leg (Fig. 1). Pulmonary examination was normal. His body temperature reached 40 C. Laboratory investigations revealed a white blood cell (WBC) count of 11.3 9 10 cells/L with 80 % neutrophils and a C-reactive protein up to 122 mg/L. Body computed tomography (CT) scan was remarkable for significant retroperitoneal adenopathies next to the inguinal lymph nodes. Finally, Francisella tularensis was isolated from the skin lesion towards the ankle. The patient received antibiotic treatment associating doxycycline and amoxicillin/clavulanic acid, the latter being stopped after 1 week when absence of sensitivity was documented. At this moment, the patient was afebrile and cough had disappeared but the inguinal swelling had increased in size to 60 9 80 mm with an underlying fluid collection, persisting despite doxycycline being continued (Fig. 2). Hence, inguinal abscess was evacuated surgically, 3 weeks after the first symptoms. Polymerase chain reaction (PCR) performed on the abscess fluid confirmed the initial result of the skin lesion, whereas cultures remained sterile. In the follow-up, the patient was well, without recrudescence of abscess; doxycycline treatment had been continued for a total duration of 4 weeks.