Clinical Scorecard: Tularemia in Children: An Overlooked Infection in Denmark

At a Glance

Key Highlights

• Denmark reported 109 laboratory-confirmed cases from 2013 through 2024 and 32 cases in 2025, although whether this reflects geographic expansion or increased recognition and testing remains uncertain.

• Ulceroglandular tularemia, the most common form in Europe, is characterized by a punched-out inoculation ulcer and regional lymphadenopathy.

• Both reported children were initially treated for presumed bacterial infection with beta-lactam antibiotics but did not improve.

• Routine bacterial cultures may remain negative because F. tularensis is fastidious and requires specialized culture media and laboratory handling.

• Serology and PCR have complementary diagnostic roles; antibodies may be undetectable early, whereas PCR of lymph node aspirates or biopsy specimens can provide earlier confirmation.

Guideline-Based Recommendations

Diagnosis

• Consider tularemia in children with persistent fever and regional lymphadenitis, particularly after possible arthropod bites or animal exposure.

• Absence of a recalled tick bite or wildlife contact does not exclude the diagnosis.

• Look for an adjacent punched-out inoculation ulcer and use serology and PCR for microbiological confirmation.

Management

• Reconsider the diagnosis when presumed bacterial lymphadenitis or soft tissue infection does not respond to beta-lactam therapy.

• Doxycycline is commonly used; fluoroquinolones may be considered in more severe cases, with abscess formation, or when clinical response is inadequate.

• Treatment should be individualized because the optimal duration of pediatric therapy remains uncertain.

Monitoring & Follow-up

• Monitor fever, lymphadenopathy, inoculation-ulcer healing, and development of lymph node suppuration.

• Assess clinical response throughout treatment because prolonged courses may be required in complicated cases.

Risks

• Delayed diagnosis is associated with prolonged illness, persistent lymphadenopathy, and increased risk of suppuration requiring drainage.

• F. tularensis is intrinsically resistant to beta-lactam antibiotics.

Patient & Prescribing Data

The report described two boys, aged 10 and 13 years. One improved after doxycycline was changed to ciprofloxacin; the other achieved fever resolution and progressive ulcer healing after 4 weeks of doxycycline. The relative contributions of antimicrobial modification, treatment duration, and the natural disease course could not be determined in the first case.

Clinical Best Practices

• Consider tularemia when fever and regional lymphadenitis persist despite beta-lactam treatment.

• Examine the corresponding drainage area for a punched-out inoculation ulcer.

• Obtain a detailed exposure history while recognizing that arthropod bites or animal contact may not be recalled.

• Use serology and PCR as complementary tests and initiate appropriate individualized antimicrobial therapy promptly.

Related Resources & Content

• Ellis J, Oyston PCF, Green M, Titball RW. Tularemia. Clin Microbiol Rev. 2002;15(4):631–646.

• Hestvik G, Warns-Petit E, Smith LA, et al. The status of tularemia in Europe in a one-health context: A review. Epidemiol Infect. 2015;143(10):2137–2160.

• Christensen CE, Horsholt K, Aftab H, et al. Tularæmi [Tularaemia]. Ugeskr Laeger. 2025;187(21):V11240819.

• Johansson A, Berglund L, Eriksson U, et al. Comparative study of doxycycline and ciprofloxacin for treatment of tularemia. Clin Infect Dis. 2001;33(2):267–273.

• Ørbæk M, Lebech AM, Helleberg M. The clinical spectrum of tularemia—two cases. IDCases. 2020;21:e00890.

• Haulrig MB, Mathiasen G, Nielsen RM, Kromann CB, Krogfelt KA, Wiese L. Two cases of tick-borne transmitted tularemia on Southern Zealand, Denmark. APMIS. 2020;128(1):61–64.

• Gustafsson F, Fjordside L, Harritshøj LH, et al. A nationwide seroprevalence study of Francisella tularensis in Denmark. Ticks Tick Borne Dis. 2026;17(2):102625.

• Arnold B, Trawinski H, Kellner N, et al. Clinical characteristics and treatment strategies in a cohort of patients with tularemia: A retrospective multicenter analysis of 65 cases in Germany. Antibiotics (Basel). 2025;14(11):1169.