REPLY

Tularemia: a re-emerging condition in Turkey which may berelated with contaminated spring water in rural areas

Yusuf Kızıl • Utku Aydil

Published online: 5 November 2013

� Springer-Verlag Berlin Heidelberg 2013

Dear Sir,

We would like to thank Yusuf Kemaloglu for his interest in

our article: Kızıl et al. [2]. Dr. Kemaloglu [1] deeply

investigated and kindly informed us about historical roots

of tularemia in Turkey. We appreciate the contribution of

Dr. Kemaloglu from a historical perspective. Since the first

biological warfare as Dr. Kemaloglu stated, tularemia

agent Francisella tularensis is still regarded as a potential

biological weapon [1]. However, in war times, tularemia

outbreaks are encountered due to poor hygiene and

increased exposure to reservoirs and vectors. As a result,

instead of biological attacks, war itself may be the primary

cause of outbreaks.

Although our aim was not to define an outbreak or a

regional feature of the disease, his prediction was right

about homelands of the patients. Most of the patients (10

patients) were from the same village of Corum province

(Central Anatolia) and one patient had a travel history to

that village. In addition, the patients also stated that the

disease was present in many other inhabitants of the village

which reflects an outbreak. The cause of the outbreak was

probably contamination of drinking water source of the

village by rats. As we have reported in our paper, the

glandular form is the most common one in our series, and

only 36.8 % presented with either oropharyngeal or ocular

lesions [2]. Therefore, as Dr. Kemaloglu stated, this form

could be a new burden of the disease without any entry-

point lesions. Some recent studies reporting high glandular

form incidence rates also support this hypothesis [3, 4].

Hence, we think that the source of infection still could be

spring water in rural areas, although only 31.6 % had

oropharyngeal forms.

Our primary treatment choice was medical treatment

and surgical drainage of suppurated adenopathies, but

surgically or spontaneously drained lymph nodes heal with

extensive scar formation. In certain cases with long-lasting

and large neck mass with overlying skin involvement, we

thought that a comprehensive surgical resection of the

involved skin along with the diseased lymph nodes may be

a more effective solution. Therefore, a group of patients

with a mean symptom duration of approximately 3 months

were treated with superselective neck dissection and the

results were quite satisfactory. This management pattern is

comparable to the surgical treatment of atypical myco-

bacterial neck infections which are also resistant to medical

therapy. We concluded that in patients with extensive neck

involvement, immediate and effective results could be

achieved with excision of involved skin and superselective

neck dissection.

Conflict of interest None.

References

1. Kemaloglu YK (2013) Letter regarding ‘‘Characteristics and

management of intractable neck involvement in tularemia’’. Eur

Arch Otorhinolaryngol 270:385–386

2. Kızıl Y, Aydil U, Cebeci S, Guzeldir OT, Inal E, Bayazıt Y (2012)

Characteristics and management of intractable neck involvement

in tularemia: report of 19 patients. Eur Arch Otorhinolaryngol

269:1285–1290

Y. Kızıl � U. Aydil

Department of Otorhinolaryngology, Gazi University School of

Medicine, Ankara, Turkey

Y. Kızıl (&)

Gazi Un. Tıp. Fak. KBB A.D., Besevler, 06500 Ankara, Turkey

e-mail: yusufkizil@yahoo.com

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Eur Arch Otorhinolaryngol (2014) 271:205–206

DOI 10.1007/s00405-013-2802-8

3. Koc S, Duygu F, Sogut E, Gurbuzler L, Eyibilen A, Aladag I

(2012) Clinical and laboratory findings of tularemia: a retrospec-

tive analysis. Kulak Burun Bogaz Ihtis Derg 22:26–31

4. Caglı S, Vural A, Sonmez O, Yuce I, Guney E (2011) Tularemia: a

rare cause of neck mass, evaluation of 33 patients. Eur Arch

Otorhinolaryngol 268:1699–1704

206 Eur Arch Otorhinolaryngol (2014) 271:205–206

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