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The Journal of the American Board of Family Practice 16:339-342 (2003)
© 2003 American Board of Family Practice

Medical Practice

Missed Sentinel Case of Naturally Occurring Pneumonic Tularemia Outbreak: Lessons for Detection of Bioterrorism

Zygmunt F. Dembek, PhD, Ronald L. Buckman, MD, Stephanie K. Fowler, MD and James L. Hadler, MD

From the Connecticut Department of Public Health (ZFD, JLH), Hartford, and Bolton Family & Sports Medicine (RLB, SKF), Bolton, Conn

Correspondence: Address reprint requests to Zygmunt F. Dembek, PhD, Connecticut Department of Public Health, 410 Capitol Ave, MS #11EPI, PO Box 340308, Hartford, CT 06134-0308

Background: Family physicians are likely to care for patients that have been exposed to diseases associated with bioterrorism. Persons with seemingly nondescript initial disease symptoms could be harbingers of a larger outbreak, whether naturally occurring or purposefully created.

Methods: We report a missed sentinel case of pneumonic tularemia associated with a naturally occurring outbreak. The patient’s initial clinical symptoms and signs were nondescript, and the diagnosis was recognized by subsequent blood tests. The medical literature was searched using the key words "tularemia," "bioterrorism," "index of suspicion," and "sentinel case."

Results and Conclusions: Being alert to possible unexpected causes of a pneumonic summer illness in a patient with associated weight loss might have led to an earlier diagnosis of this sentinel case tularemia and its association with the subsequent outbreak. Individual patients are likely to visit a physician’s office after a purposeful bioterrorism event. Greater efforts must be made to increase awareness in all primary care physicians who might see patients exposed to a bioterrorism illness.






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Copyright © 2003 by the American Board of Family Medicine.