Erythema Nodosum: An Unusual Clinical Manifestation of Oropharyngeal Tularemia

Tularemia is a zoonotic infection caused by Francisella tularensis. Oropharyngeal tularemia, one of the several clinical forms of tularemia identified, is typically characterized by fever, sore throat, cervical buboes, and rarely, cutaneous lesions. Here we describe an uncommon clinical manifestation of oropharyngeal tularemia with erythema nodosum, an inflammatory condition that causes tender nodules to form on the lower legs. A 45-year-old woman with fever, sore throat, unilateral cervical buboes, and erythema nodosum on both legs was diagnosed with oropharyngeal tularemia based on clinical manifestations and positive latex agglutination testing. We prescribed a 14-day course of intramuscular streptomycin, which resulted in the complete recovery of the patient. It is unusual for tularemia to manifest with erythema nodosum as a primary symptom, particularly one that persists throughout the illness. Although the cause of erythema nodosum is unknown in nearly half of cases, it is important to identify or exclude possible infectious causes of this condition, including tuberculosis, Valley fever, cat scratch disease, and, as illustrated in the case described herein, tularemia.