Pediatric tularemia in Denmark. A forgotten disease

Tularemia is a zoonotic infection caused by Francisella tularensis (F. tularensis). Although tularemia has historically been considered rare in Denmark, increasing numbers of diagnosed cases and recent seroepidemiological data suggest that the infection is increasingly recognized and may be more widespread than previously appreciated. This paper describes two pediatric cases presenting with persistent fever, punched-out inoculation ulcer (eschar) and local (inguinal)lymphadenitis, initially misdiagnosed as a common bacterial soft tissue infection. Both cases highlight delayed diagnosis, lack of response to first line antibiotics (beta lactam antibiotic), and the importance of considering tularemia in local persistent lymphadenitis especially combined with an adjacent punched out skin ulcer.