title: Missed sentinel case of naturally occurring pneumonic tularemia outbreak: lessons for detection of bioterrorism.
abstract: BACKGROUND
  Family physicians are likely to care for patients that have been exposed to diseases associated with bioterrorism. Persons with seemingly nondescript initial disease symptoms could be harbingers of a larger outbreak, whether naturally occurring or purposefully created.
  
  
  METHODS
  We report a missed sentinel case of pneumonic tularemia associated with a naturally occurring outbreak. The patient's initial clinical symptoms and signs were nondescript, and the diagnosis was recognized by subsequent blood tests. The medical literature was searched using the key words "tularemia," "bioterrorism," "index of suspicion," and "sentinel case."
  
  
  CONCLUSIONS
  Being alert to possible unexpected causes of a pneumonic summer illness in a patient with associated weight loss might have led to an earlier diagnosis of this sentinel case tularemia and its association with the subsequent outbreak. Individual patients are likely to visit a physician's office after a purposeful bioterrorism event. Greater efforts must be made to increase awareness in all primary care physicians who might see patients exposed to a bioterrorism illness.
authors.affiliation: Connecticut Department of Public Health, Hartford, CT 06134, USA.
authors.forename: Zygmunt F
authors.initials: ZF
authors.lastname: Dembek
authors.forename: Ronald L
authors.initials: RL
authors.lastname: Buckman
authors.forename: Stephanie K
authors.initials: SK
authors.lastname: Fowler
authors.forename: James L
authors.initials: JL
authors.lastname: Hadler
mesh_terms: D023482:Bioterrorism / Q000517:prevention & control*; D003140:Communicable Disease Control; D004196:Disease Outbreaks; D005604:Francisella tularensis / Q000302:isolation & purification; D006801:Humans; D008297:Male; D008404:Massachusetts / Q000453:epidemiology; D008875:Middle Aged; D014406:Tularemia / Q000175:diagnosis* / Q000453:epidemiology* / Q000635:transmission