Pulmonary tularemia leading to a relapse of tularemia orchitis in a patient on TNF-alpha inhibitor.

PURPOSE: Tularemia represents a zoonotic infection that poses particular diagnostic and therapeutic challenges in immunocompromised patients. We present a rare case of tularemia orchitis in a patient receiving tumor necrosis factor alpha (TNF alpha) inhibitor treatment.

METHODS

We conducted a case analysis of a 71-year-old farmer receiving adalimumab for psoriatic arthritis who developed sequential pulmonary and genitourinary manifestations of tularemia. Clinical presentation, laboratory findings, microbiological identification through culture and polymerase chain reaction testing, imaging studies, and histopathological examination were documented. Treatment response and clinical follow-up were monitored throughout the disease course.

RESULTS

The patient initially presented with pneumonic tularemia confirmed by positive blood cultures. Following apparent clinical resolution with doxycycline therapy, he developed orchitis 3 months later requiring unilateral orchiectomy. Polymerase chain reaction testing confirmed Francisella tularensis as the causative pathogen in testicular tissue. Histological examination revealed dense inflammatory infiltration with histiocytes, neutrophils, and T‑lymphocytes. Combination therapy with doxycycline and ciprofloxacin achieved clinical remission, although fluoroquinolone-induced peripheral neuropathy necessitated treatment modification.

CONCLUSION

Patients receiving tumor necrosis factor alpha inhibitors demonstrate increased susceptibility to tularemia manifestations and potential disease relapse. The blood-testis barrier may limit antibiotic penetration, contributing to treatment failure with monotherapy. Enhanced clinical awareness and consideration of combination antimicrobial therapy may be warranted in immunocompromised patients with tularemia, particularly those residing in endemic regions.