Table 1.

Cases of tularemia in immunocompromised patients from litterature.

Age Country	Gender	Year	Pathology / Immunosuppressive Therapy	Main Symptoms	Imaging Results	Biological Results	Treatment	Outcome	Author
12 USA	M	1996	AIDS: CD4 0/mm3	Fever; nausea; headaches; photophobia without meningismus; abdominal pain with hepatosplenomegaly; cough; tachypnea	Chest radiograph: left lower lobe infiltrate	Blood cultures: positives for F. tularensis after 13 days. Tularemia Serology: negative	Ceftazidime + Vancomycin IV 10 days Gentamicin + ampicillin IV 7 days first relapse Gentamicin 10 days then tetracycline 14 days second relapse tetracycline 21 days	Complete recovery (after 2 relapses)	[45]
14 USA	M	1997	Chronic granulomatous disease	Fever; unproductive cough; recurring after treatment and lobectomy	Chest radiograph: left lower-lobe infiltrate with pleural effusion. After 3 months Chest CT scan: necrotic area within the left lower lobe	Pleural and lung culture: negative Tularemia serology: positive	Doxycycline 7 days relapse Doxycycline 14 days Lower left lobe Lobectomy relapse Gentamicin + Ticar/clav IV 21 days + Doxy 30 days	Complete recovery (after 2 relapses)	[33]
50 USA	M	1999	Liver transplant: Prednisolone, 10 mg/day Azathioprine, 75 mg/day	Fever, arthromyalgia, and pneumonia	Chest radiograph: right middle lobe infiltrate	Bronchoalveolar lavage fluid testing: negative Blood cultures: positives for F. tularensis subsp. holarctica after 9 days.	Levofloxacin: 500 mg/day, 21 days	Complete recovery (no relapse)	[46]
33 USA	M	1999	AIDS: CD4 220/mm3	Fever; dry cough; headache; myalgia; pneumonia and no modification of the previous lymphadenopathies	Chest radiograph: ill-defined bibasilar abnormalities	Blood cultures: positive for F. tularensis subsp. holarctica after 21 days. Urine and Sputum cultures: negative	Levofloxacin: 500 mg/day, 10 days	Complete recovery (no relapse)	[46]
61 USA	M	1999	7 months after peripheral blood stem cell transplantation for acute myeloid leukemia (AML) conditioning: busulfan + cyclophosphamide	Fever, chills and fatigue	Chest CT scan: right lower lobe nodule	Culture of nodule needle aspiration: positive for F. tularensis after 6 days	Imipenem IV 7 days then Ciprofloxacin 750 mg b.i.d 28 days	Complete recovery (no relapse)	[47]
43 USA	M	2003	Chemotherapy followed by bone marrow transplant for ALL Conditioning not precised	Fever, lethargy, inguinal lymph nodes expansion	none	Blood cultures positives after 4 days, identification of F. tularensis subsp. tularensis post mortem	Imipenem + vancomycin, 12 days with Gentamicin 5 days	Deceased (on d14 of symptoms)	[32]
69 USA	M	2004	Kidney transplant: mycophenolate mofetil rapamycin prednisone	Fever, chills, fatigue, vomiting, diarrhea	Chest radiograph: patchy infiltrate in the left lung	Blood culture positive for F. tularensis subsp. tularensis after 7 days	Doxycycline for 14 days	Complete recovery (no relapse)	[48]
59 USA	M	2005	11 years post kidney transplant: prednisone; mycophenolate mofetil; cyclosporine	Persistent fever	Chest CT-scan: multiple pulmonary nodules	Nodule biopsy cultures: positive for F. tularensis	Fluoroquinolone (dosage and duration unknown)	Clinical improvement	[49]
58 France	M	2009	Rheumatoid arthritis: methotrexate + adalimumab	Fever, plaque on the left leg with central necrotic area, enlarged left inguinal lymph node with skin fistula	None	Skin biopsy histopathology: epithelioid granulomas with giant cells and central necrosis. Tularemia serology: positive PCR for F. tularensis: positive on a lymph node biopsy	Doxycycline for 6 weeks	Complete recovery (no relapse)	[24]
54 Germany	M	2010	4 years after stem cell transplant for AML. With chronic graft-versus-host-disease: tacrolimus + steroids	Fever, chills, dyspnea	CT scan: large infiltrate in the right upper lobe	Blood culture: positive for F. tularensis subsp. holarctica after 7 days	Imipenem + levofloxacin for 8 days + Doxycycline for 8 days	Complete recovery	[50]
69 France	M	2010	15 years post kidney transplant: prednisolone; mycophenolate mofetil; cyclosporine a	Fever, chills, cough and sputum	Chest radiograph: bilateral interstitial infiltrates	Blood culture: positive for F. tularensis after 10 days. PCR on cultured colony: positive for F. tularensis subsp. holarctica	Ciprofloxacin 500 mg/day (adapted to renal function) for 14 days	Complete recovery (no relapse)	[51]
24 Turkey	M	2012	12 months after kidney transplant. prednisolone; mycophenolate mofetil; tacrolimus	Cervical lymphadenopathy	none	Lymph node biopsy: chronic necrotizing granulomatous inflammation Real-time PCR–for tularemia on lymph node: positive. Serology: positive	Doxycycline for 10 days	Complete recovery (no relapse)	[52]
32 France	W	2014	Severe psoriatic arthritis: certolizumab; methotrexate	Fever, right elbow pain with functional impairment.	Initial Elbow CT scan: large collection in the right elbow. Second CT scan: communicating axillary collections compatible with necrotic confluent adenopathy	Glandular abscess aspirate culture: positive after 4 days. F. tularensis subsp. holarctica identified after amplification and sequencing of 16SrDNA	Ciprofloxacin + gentamicin for 14 days; then ciprofloxacin for 14 days relapse; ciprofloxacin + doxycycline for 4 months	Complete recovery (after 1 relapse)	[26]
51 France	M	2015	7 years after liver transplant: tacrolimus mycophenolate mofetil	Septic shock, acute respiratory distress syndrome, ketoacidosis,	Chest radiograph: bilateral alveolar opacities Thoracic CT-Scan: mediastinal lymphadenopathies and bilateral nodular lesions	Blood culture: positive after 5 days. Strain unidentified Amplification and sequencing allowed identification of Francisella tularensis subsp. holartica	Ciprofloxacin 500 mg b.i.d for 14 days	Complete recovery (no relapse)	[9]
64 France	M	2016	4 Years after heart transplantation: prednisolone cyclosporin mycophenolate mofetil	Fever, chills, night sweats, unproductive cough, progressive respiratory distress	CT-scan: pleural effusion and mediastinal lymphadenopathies PET-scan: hypermetabolism of mediastinal and celiacomesenteric lymphadenopathies and pulmonary parenchymatous lesions	Pleural liquid cultures: negative. PCR F. tularensis positive on two lymph node biopsies. Culture of lymph node biopsy: positive for Francisella tularensis subsp. holarctica	Ciprofloxacin 750 mg b.i.d. + gentamicin 300 mg for 7 days; then ciprofloxacin for 14 days	Complete recovery (no relapse)	[9]
51 USA	M	2017	Rheumatoid arthritis: infliximab, leflunomide	Fever, fatigue, diarrhea, chest pain, confusion	CT scan: multiple pulmonary parenchymal nodules with mediastinal adenopathy and a right pleural effusion	Lung biopsy culture: positive for Francisella tularensis	Intravenous infusion of gentamicin and oral ciprofloxacin	Complete recovery (no relapse)	[24]
25 Switzerland	M	2019	Psoriasis adalimumab	Fever, chills, weight loss, night sweats, diarrhea, dysuria, headaches, painful neck lymph node	Chest CT scan: mass near the right hilus, infiltrations in the left and right upper lung lobe, mediastinal lymphadenopathy	Blood cultures: negative lymph nodes biopsy: central necrotizing epithelioid cell granulomas PCR of the biopsy was positive for F. tularensis ssp. Holarctica serology: positive	Ciprofloxacin 750 mg bid. For 18 days	Complete recovery	[53]