LETTERS

Rabbit Tularemia wild-captured rabbits in a 10-acre, was an acute, multifocal, necrotizing fenced area reserved for the training hepatitis (Figure). The differential and Hepatic of hunting dogs. Beginning in the diagnoses for acute, multifocal, ne- Coccidiosis in summer of 2009, a gradual rabbit die- crotizing heptatitis in a rabbit include Wild Rabbit off occurred, progressing to almost tularemia, Tyzzer disease, listeriosis, complete depopulation by May 2010. and salmonellosis. In this instance, F. To the Editor: Tularemia is a The liver from the dead rabbit was tularensis was identifi ed by bacterial highly pathogenic zoonosis caused by submitted to the University of Mis- culture (3) and PCR as previously de- the gram-negative intracellular bac- souri Veterinary Medical Diagnostic scribed (4). No other pathogenic bacte- terium Francisella tularensis. F. tu- Laboratory (Columbia, MO, USA). ria were isolated on culture. These re- larensis causes serious septicemia in Gross examination showed the liver sults were reported to the veterinarian, animals, especially wild rodents and contained multifocal to coalescing, the owner, and public health offi cials. lagomorphs (rabbits and hares), and linear, yellow to gray nodules consis- All remaining biological specimens potentially fatal, multisystemic disease tent with the classical appearance of were immediately discarded follow- in humans. The human mortality rate hepatic coccidiosis. Although no gross ing the University of Missouri’s select can reach 30% in untreated persons evidence of tularemia was observed, agent protocols, and further analysis (1). F. tularensis is listed as a category the specimen was treated as poten- was halted, preventing further typing A bioterrorism agent by the Centers tially infected with tularemia because of the isolated F. tularensis. for Disease Control and Prevention the veterinarian requested F. tularensis According to the Centers for Dis- alongside the causative agents of an- testing. Samples were collected and ease Control and Prevention, ≈126 thrax, plague, smallpox, botulism, and processed for bacteriologic culture, cases of tularemia are reported annu- viral hemorrhagic fevers. Generally, PCR, and histologic evaluation within ally in the United States (5). During lesions associated with septicemic tu- the confi nes of a certifi ed biological 2000–2008, Missouri had the highest laremia include multifocal 1–2-mm, hood. number of reported cases (228) fol- white foci of necrosis in the liver, The liver contained 2 distinct mi- lowed by Arkansas (149) (5). Two spleen, lymph nodes, and lungs. croscopic lesions. The fi rst was severe subspecies of F. tularensis are en- Eimeria stiedae is the causative biliary hyperplasia with numerous in- demic to the United States: the highly agent of hepatic coccidiosis, a com- traepithelial coccidia, consistent with virulent F. tularensis subsp. tularensis mon disease of wild rabbits (2) that hepatic coccidiosis, as was anticipat- (type A) and the moderately virulent F. can result in severe hepatic injury ed. The second, more surprising lesion tularensis subsp. holarctica (type B). and death in juveniles and neonates. The gross lesion associated with he- patic coccidiosis is unique and nearly pathognomonic. Because E. stiedae causes proliferation of bile duct epi- thelial cells, affected livers contain multifocal, well-demarcated, linear, occasionally branching, bosselated, yellow to pearl-gray lesions that re- fl ect the course of the biliary tree. We describe a unique case of tu- laremia in a rabbit co-infected with E. stiedae. This case was initially mis- diagnosed as simple E. stiedae infec- tion on the basis of the classical gross lesions of hepatic coccidiosis, which overshadowed the more subtle tulare- mia lesions. A juvenile wild rabbit was brought to a local veterinary clinic for postmortem examination. The owner, Figure. Liver from a juvenile wild rabbit with numerous oval Eimeria stiedae oocysts in located in southwestern Missouri near the convoluted hyperplastic bile ducts (asterisks) and necrotizing hepatitis (arrow) by the Arkansas–Kentucky border, raises Francisella tularensis. Hematoxylin and eosin stain; scale bar = 200 μm.

2016 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 16, No. 12, December 2010 LETTERS

Transmission of the bacterium occurs References Imported primarily through bites from arthro- 1. Foley JE, Nieto NC. Tularemia. Vet Mi- Leishmaniasis in pods, including the dog tick (Derma- crobiol. 2010;140:332–8. DOI: 10.1016/j. centor variabilis), the wood tick (D. vetmic.2009.07.017 Dogs, US Military andersoni), the lone star tick (Ambly- 2. Hobbs RP, Twigg LE. Coccidia (Eimeria Bases, Japan omma americanum), and the deer fl y spp.) of wild rabbits in southwestern Aus- tralia. Aust Vet J. 1998;76:209–10. DOI: (Chrysops spp.). In addition, contact 10.1111/j.1751-0813.1998.tb10131.x To the Editor: Leishmaniasis is with infected animals, most com- 3. Ellis J, Oyston PC, Green M, Tit- found in canids in ≈50 of the 88 coun- monly rabbits, wild rodents, and cats, ball RW. Tularemia. Clin Microbiol tries where leishmaniases are found in is another common route of transmis- Rev. 2002;15:631–46. DOI: 10.1128/ humans (1). In Japan, 2 cases of im- CMR.15.4.631-646.2002 sion to humans (1,6). 4. Long GW, Oprandy JJ, Narayanan RB, ported canine leishmaniasis have been Tularemia occurs in various ani- Fortier AH, Porter KR, Nacy CA. Detec- documented in dogs from Spain (2,3). mal species. Lagomorphs, rodents, and tion of Francisella tularensis in blood by We report 2 cases of leishmaniasis in sheep are most susceptible; infected polymerase chain reaction. J Clin Micro- dogs in which dermatitis developed biol. 1993;31:152–4. animals are frequently found dead or 5. Centers for Disease Control and Preven- mainly on the face. Leishmaniasis was moribund. Carnivores are less suscep- tion. Reported tularemia cases by state— diagnosed from results of a serologic tible; however, feline tularemia occurs United States, 2000–2008 [cited 2010 rk39 test, followed by PCR of skin sporadically, and human infections as- Jun 23]. http://www.cdc.gov/tularemia/ lesion specimens for the Leishmania Surveillance/Tul_CasesbyState.html sociated with bites and scratches from 6. Farlow J, Wagner DM, Dukerich M, Stan- spp.–specifi c small subunit (SSU) infected cats have been recognized (7). ley M, Chu M, Kubota K, et al. Francisella rRNA gene. Because the dogs had In addition to arthropod bites, contact tularensis in the United States. Emerg In- lived on a US military base in Sicily, with infected dead rabbits or their tis- fect Dis. 2005;11:1835–41. Italy, for 3 years before their owners 7. Arav-Boger R. Cat-bite tularemia in a sev- sues appears to be the most common enteen-year-old girl treated with ciprofl ox- were transfered to Japan, the animals source of human infection. A wide acin. Pediatr Infect Dis J. 2000;19:583–4. were likely infected with L. infantum variety of case reports have been pub- DOI: 10.1097/00006454-200006000-00024 in Italy. lished describing unique incidences of 8. Agger WA. Tularemia, lawn mow- Animal 1 was a 6-year-old female ers, and rabbits’ nests. J Clin Micro- rabbit–human transmission, includ- biol. 2005;43:4304. DOI: 10.1128/ dog that had lived in Sicily for 3 years, ing a lawn mower aerosolizing rabbit JCM.43.8.4304-4305.2005 since 2003, and had been brought to nests along with their occupants (8), 9. Jansen A, Schmidt W, Schneider T. Japan in September 2006. While she consumption of undercooked rabbit Rabbit’s revenge. Lancet Infect Dis. lived in Italy, she had exhibited alo- 2003;3:348. DOI: 10.1016/S1473-3099 meat (9), and contact with a “lucky” (03)00656-X pecic, pruritic, and crusty skin lesions, rabbit’s foot (10). 10. Ryan-Poirier K, Whitehead PY, Leggiadro mainly around the face and on the The purpose of this report is to RJ. An unlucky rabbit’s foot? Pediatrics. forearms and hind legs. alert veterinarians, veterinary labora- 1990;85:598–600. In November 2006, the dog was tory personnel, and public health offi - brought to the US Army Veterinary cials that rabbit tularemia can be easi- Address for correspondence: Dae Young Kim, Command’s Zama Veterinary Treat- ly overlooked on gross examination in Veterinary Medical Diagnostic Laboratory, ment Facility with dermatitis (online animals displaying lesions of hepatic College of Veterinary Medicine, University of Appendix Figure, panel A, www.cdc. coccidiosis, a common disease of the Missouri, 1600 E Rollins St, Columbia, MO gov/EID/content/16/12/2017-appF. wild rabbit. Therefore, all rabbits sub- 65211, USA; email: [email protected] htm) and additional signs of kid- mitted for postmortem examinations ney failure. A serum specimen was should be regarded as potentially in- positive by the rk39 dipstick test for fected with tularemia, particularly dur- diagnosis of visceral leishmaniasis ing seasons when vectors are active. (Kalazar Detect; InBios, Seattle, WA, USA). A skin punch biopsy specimen Dae Young Kim, was obtained for cultures and PCR for Thomas J. Reilly, the parasites in December 2006. Cul- Susan K. Schommer, tures of 4 skin specimens were all neg- and Sean T. Spagnoli ative, probably because of cool trans- Author affi liation: University of Missouri, portation of the samples for 1.5 days Columbia, Missouri, USA before the cultures were started. The DOI: 10.3201/eid1612.101013 dog’s condition was treated with ke- toconazole and then allopurinol. The

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