Tularemia in pediatric patients in Sivas Province: a 15-year clinical experience

Abstract

Tularemia is a clinically important yet often underrecognized cause of persistent cervical lymphadenopathy in children living in endemic regions, and delayed diagnosis may lead to prolonged morbidity, inappropriate antibiotic use, and unnecessary invasive procedures. This study aimed to evaluate the clinical, laboratory, and radiological features, treatment approaches, and outcomes of pediatric tularemia in an endemic region, and to identify distinguishing characteristics between confirmed and suspected cases. A retrospective study was conducted at a tertiary referral center between 2011 and 2025, including pediatric patients evaluated for suspected tularemia. Cases were classified as tularemia positive or negative (control) based on microbiological and serological criteria. Demographic, clinical, laboratory, and radiological data, along with treatment approaches, were compared between groups. Statistical analyses were performed using appropriate tests according to data distribution, with p < 0.05 considered statistically significant. A total of 71 patients were included (31 tularemia, 40 controls). Rural residence was significantly more common among patients with tularemia (80.0% vs. 55.0%, p = 0.029). Submandibular lymphadenopathy (60.7% vs. 34.7%), nodal necrosis (25.8% vs. 2.5%), and hypoechoic lymph nodes (30.0% vs. 10.0%) were observed more frequently in the tularemia group, whereas conglomerated lymph nodes were more common among tularemia-negative patients (17.2% vs. 47.5%) (all p < 0.05). Patients with tularemia had higher leukocyte, neutrophil, lymphocyte, platelet counts, erythrocyte sedimentation rate levels, and lower albumin concentrations (all p < 0.05). Aminoglycosides were the most frequently administered antimicrobial agents after diagnosis (64.5%), whereas beta-lactam antibiotics were commonly prescribed before tularemia was recognized (74.2%). Surgical intervention was required in more than half of the patients (58.1%). Reactive (60%) and EBV-associated lymphadenopathy (12.5%) constituted the most common final diagnoses among tularemia-negative cases. Tularemia should be considered in children with cervical lymphadenopathy and oropharyngeal symptoms in endemic regions, particularly those with rural residence. Submandibular involvement, necrotic and hypoechoic lymph nodes, and a lower tendency for conglomeration may help distinguish tularemia from other causes of cervical lymphadenopathy. Early recognition and appropriate antimicrobial therapy may reduce the need for surgical intervention.