To describe two pediatric cases of ulceroglandular tularemia in Denmark and highlight diagnostic challenges in a setting where the infection has traditionally been considered uncommon.
Approach:
Case presentation: Two boys, aged 10 and 13 years, presented with fever, inguinal lymphadenitis, and adjacent punched-out inoculation ulcers. Their clinical courses, diagnostic testing, antimicrobial treatment, and outcomes were described.
Diagnostic evaluation: Francisella tularensis infection was assessed using serology and, in one case, PCR of a lymph node biopsy after initial treatment for presumed bacterial soft tissue infection failed.
Key Findings:
Denmark recorded 109 laboratory-confirmed tularemia cases from 2013 through 2024 and 32 cases in 2025; a nationwide study detected F. tularensis antibodies in 2.2% of Danish blood donors.
Both children were initially treated with beta-lactam antibiotics for presumed common bacterial infection without clinical improvement.
The combination of persistent fever, regional lymphadenitis, and an adjacent punched-out ulcer prompted suspicion of ulceroglandular tularemia.
One child improved after treatment was changed from doxycycline to ciprofloxacin; the other recovered after a prolonged course of doxycycline.
Neither recent travel nor known wildlife exposure was reported, emphasizing that the absence of a recalled tick bite or animal contact does not exclude tularemia.
Interpretation:
In children, tularemia may be overlooked because its manifestations resemble common bacterial lymphadenitis or soft tissue infection and the disease is infrequently suspected in low-incidence settings. Failure to respond to beta-lactam therapy and identification of an adjacent punched-out ulcer should prompt diagnostic reconsideration.
Limitations:
The report describes only two pediatric cases, limiting broader conclusions about presentation, diagnosis, and treatment.
Relevant arthropod bites or animal exposures may have gone unnoticed or been unrecalled, limiting identification of the transmission source.
In the first case, the relative effects of changing antimicrobial therapy, cumulative treatment duration, and the natural disease course could not be determined.
Conclusion:
Tularemia should be considered in children with persistent fever and regional lymphadenitis, particularly when an adjacent punched-out ulcer is present or beta-lactam therapy fails. Increased awareness, timely diagnostic testing, and appropriate antimicrobial treatment may reduce delayed diagnosis and suppurative complications.
