in late february 2006 , a 27-year - old pregnant woman , at 6 weeks gestation , was referred to grenoble university hospital , grenoble , france , for investigation of persistent left cervical lymphadenopathy with fever .
the lymphadenopathy occurred 3 weeks earlier , along with a sore throat , and persisted despite 10 days treatment with amoxicillin ( 3 g daily ) .  
at admission , the patient was febrile ( 38c ) and had a tender , swollen , submaxillary cervical lymph node on the left side .
magnetic resonance imaging of the left cervical region showed a large mass extending from the parotid region to the submandibular region , with hypo- and hypersignals in t1- and t2-weighted imaging , respectively .  
lymph node tissue was obtained by needle aspiration , and examination revealed nonspecific lesions of lymphadenitis .
laboratory test results showed moderate inflammatory syndrome ( c - reactive protein 67 mg / l ) .
serologic results were negative for hiv , hepatitis b and c viruses , rubella virus , treponema pallidum ( syphilis ) , coxiella burnetii ( q fever ) , and borrelia , bartonella , brucella , and legionella spp . and showed only residual igg - type antibodies against cytomegalovirus , epstein - barr virus , herpes simplex virus , parvovirus , mycoplasma pneumoniae , and chlamydophila pneumoniae .   because we suspected
severe streptococcus pyogenes infection , a second course of amoxicillin was administered for 13 additional days .
after initial clinical improvement , the patient relapsed , and the lymphadenopathy evolved to suppuration and necrosis . in march 2006
, a large amount of pus was surgically drained from the site , and inflamed lymph nodes were removed .
the patient denied receiving any tick bite but reported that she regularly fed domestic rabbits in cages .
her symptoms began a few days after she killed and skinned rabbits , which were then kept frozen but not eaten by the family .  
routine cultures and mycobacterial cultures remained sterile , but f. tularensis dna was detected in lymph node samples by using specific real - time pcr targeting the gene encoding a 23-kda surface protein ( 5 ) .
pcr amplification and sequencing of the 16s rdna23s rdna intergenic spacer region ( 5 ) directly from lymph node tissue confirmed the presence of dna from f. tularensis subsp .
serum samples collected in late february and on march 15 , 2006 , were tested by using an immunofluorescence assay and a homemade f. tularensis antigen ( 5 ) .
both samples were positive , with igm and igg titers of 320 ( cutoff titers of > 160 ) .   because the patient was pregnant and tularemia in france
holarctica ( 2 ) , which are naturally susceptible to macrolides , she was treated with azithromycin ( 500 mg / d for 6 weeks ) .
the patient reported that the rabbits were reared outdoors , in floor - level , wire - mesh cages ; therefore , we suspected the animals were infected with f. tularensis through contact with wild fauna .
attempts to detect f. tularensis in pieces of the frozen rabbits by culture and pcr tests were unsuccessful .
clinical symptoms of tularemia are primarily related to the portal of entry of bacteria , the f. tularensis strain virulence , and the immune status of the patient .
the incubation period is usually 13 days but may last up to 15 days ( 3,6 ) .
the primary clinical forms are glandular and ulceroglandular ( skin inoculation ) , oculoglandular ( conjunctival inoculation ) , oropharyngeal ( oral contamination ) , pneumonic ( inhalation of an infected aerosol ) , and typhoidal ( various modes of infection ) ( 2,7 ) .
tularemia may be severe and even fatal ; patients with lymphadenopathy may experience lymph node suppuration in 30% of cases ( 1 ) .
our patient s symptoms were fever , pharyngitis , and cervical lymphadenopathy ; treatment with a -lactam drug did not improve her condition , which rapidly evolved to local suppuration , a sign that should prompt physicians to consider oropharyngeal tularemia in disease - endemic regions . because tularemia cases remain extremely rare in the french alps , where the patient lived , this diagnosis was not considered at the time of the first medical consultation .   because the rabbit meat was not consumed by the patient , we suspected she became infected at the time she skinned these animals
however , the animals had no overt disease at the time they were killed , so low bacterial inoculum may explain why the tests performed on rabbit meat had negative results . diagnosis of tularemia is often made by serologic tests ( 3 ) , although these are negative during the first 2 weeks following the onset of symptoms ( 1 ) . in the case described here ,
the same high antibody titers were obtained in 2 serum samples taken 2 weeks apart , which indicates that the peak secretion of specific antibodies was achieved .
culture of f. tularensis from clinical samples remains poorly sensitive , but pcr - based testing of pharyngeal swab specimens or lymph node suppurations or biopsy specimens enables rapid diagnosis of oropharyngeal tularemia and identification of the f. tularensis subspecies involved ( 1,4,5,7,8 ) .
a few tularemia cases occurring in pregnant women have been reported ( 9 ) . severe illness or death caused by infection with f. tularensis
could be a risk for a pregnant woman or her fetus ; the role of f. tularensis as an agent of abortion and intrauterine death is well recognized in sheep ( 10 ) but not in pregnant women .
a major difficulty in this instance was the choice of the antimicrobial drug regimen , because first - line antibiotics currently recommended for treatment of tularemia , including the aminoglycoside gentamicin , fluoroquinolones , and tetracyclines ( 1,2,7,8 ) , may be toxic for pregnant women or fetuses . no treatment recommendation for tularemia during pregnancy is available ( 9 ) .  
the pregnancy outcome was favorable , and the patient and the infant were healthy at 12-month follow up .
macrolides are usually not recommended for treatment of tularemia patients ( 2,7,8 ) , especially because f. tularensis subsp .
holarctica biovar 2 strains , mainly found in eastern europe and asia , are naturally resistant to macrolides ( 1114 ) .
the ketolides ( e.g. , telithromycin ) are highly active against f. tularensis in vitro ( 11,15 ) , but their use in pregnant women is currently discouraged .
this case emphasizes the usefulness of azithromycin as a first - line treatment for tularemia in pregnant women in areas where infections caused by biovar 2 strains of f. tularensis subsp .
 a pregnant woman who had oropharyngeal tularemia underwent treatment with azithromycin and lymph node resection and recovered without obstetrical complication or infection in the child . 
 azithromycin represents a first - line treatment option for tularemia during pregnancy in regions where the infecting strains of francisella tularensis have no natural resistance to macrolides . 