title: Pulmonary tularaemia: all that looks like cancer is not necessarily cancer - case report of four consecutive cases.
abstract: BACKGROUND
  Pulmonary tularaemia is a very rare disease with only a small number of cases described in the literature. So far, to our knowledge, there exists no case report of pulmonary tularaemia where PET-CT scans and follow up CT scans are available.
  
  
  METHODS
  We present four consecutive cases of pulmonary tularaemia. All patients suffered from non-specific symptoms. All patients were referred to our institution with strong suspicions of malignancy, particularly lung cancer. Diagnosis of tularaemia was made by typical findings in the aspirate of EBUS guided fine needle aspiration (necrosis, epithelioid cell aggregation) and surgical biopsy respectively, and a positive serology. In three of the four cases, the diagnosis was confirmed by positive PCR results of the tissue. PET-CT scans obtained in all four cases were indistinguishable from lesions typically seen in patients suffering from lung cancer. One of the four patients suffered from recurrence of the disease after antibiotic treatment; also this patient finally recovered after initiation of a second antibiotic regimen. One case became asymptomatic spontaneously, but this patient still received an antibiotic treatment. In one case, a follow up CT scan was unchanged compared to the initial PET-CT scan; in all other cases, the lesions disappeared almost completely.
  
  
  CONCLUSIONS
  Symptoms of patients suffering from pulmonary tularaemia are non-specific and can be of prolonged character. PET-CT scans in these cases are indistinguishable from lung cancer. The diagnosis can be established when typical findings in EBUS guided fine needle aspirates or surgical biopsies are found in combination with a positive serology. In most cases the lesions disappear in follow up CT scans after clinically successful treatment.
authors.affiliation: Clinic of Pulmonary and Sleep Medicine, Cantonal Hospital Aarau, Tellstrasse, CH-5001, Aarau, Switzerland. Patrick.Fachinger@ksa.ch.
authors.forename: Patrick
authors.initials: P
authors.lastname: Fachinger
authors.affiliation: Clinic of Pulmonary and Sleep Medicine, Cantonal Hospital Aarau, Tellstrasse, CH-5001, Aarau, Switzerland. GabrieloMauro.Tini@ksa.ch.
authors.forename: Gabrielo Mauro
authors.initials: GM
authors.lastname: Tini
authors.affiliation: Department of Pathology, Cantonal Hospital Aarau, Tellstrasse, CH-5001, Aarau, Switzerland. Rainer.Grobholz@ksa.ch.
authors.forename: Rainer
authors.initials: R
authors.lastname: Grobholz
authors.affiliation: Clinic of Thoracic surgery, Cantonal Hospital Aarau, Tellstrasse, CH-5001, Aarau, Switzerland. Franco.Gambazzi@ksa.ch.
authors.forename: Franco
authors.initials: F
authors.lastname: Gambazzi
authors.affiliation: Institute for Microbiology, Cantonal Hospital Aarau, Tellstrasse, CH-5001, Aarau, Switzerland. Hans.Fankhauser@ksa.ch.
authors.forename: Hans
authors.initials: H
authors.lastname: Fankhauser
authors.affiliation: Clinic of Pulmonary and Sleep Medicine, Cantonal Hospital Aarau, Tellstrasse, CH-5001, Aarau, Switzerland. siran@gmx.ch.
authors.forename: Sarosh
authors.initials: S
authors.lastname: Irani
mesh_terms: D000328:Adult; D001706:Biopsy; D001999:Bronchoscopy; D003937:Diagnosis, Differential; D061765:Endoscopic Ultrasound-Guided Fine Needle Aspiration; D019788:Fluorodeoxyglucose F18; D006801:Humans; D008175:Lung Neoplasms / Q000175:diagnosis*; D008297:Male; D008875:Middle Aged; D018410:Pneumonia, Bacterial / Q000175:diagnosis*; D049268:Positron-Emission Tomography; D019275:Radiopharmaceuticals; D014057:Tomography, X-Ray Computed; D014406:Tularemia / Q000175:diagnosis*
chemical_list: D019275:Radiopharmaceuticals; D019788:Fluorodeoxyglucose F18