Clinical Characteristics of Ulceroglandular Tularemia in Two Bulgarian Regions, 2014-2015: a Report of Five Cases.

We present here the first five human cases with tularemia from two regions in South Bulgaria in which there had been no previous report of the infection. The cases occurred over a period of 8 months (December 2014 - August 2015). They were treated at the Department of Infectious Diseases in Stara Zagora University Hospital, Bulgaria. We present the clinical, epidemiological and laboratory data for four men and one woman (age range 52 to 73 years). Three men were hunters, four patients took part in handling, preparing/skinning and cooking the game animals. One man marked agricultural work and contact with straw stems. After a mean incubation period of 4.8±1.4 days ulcers appeared, followed by local painful lymphadenitis. All patients presented with liver enlargement and elevation in acute phase reactants. The etiological diagnosis was made by tube agglutination test in all cases, PCR positive result was found in one. The administered antibacterial treatment was a combination of aminoglycosides and 4-quinolones with the outcome being favorable for all patients. The current report suggests presence of Francisella tularensis in South Bulgaria.