Clinical and Epidemiologic Characteristics of Pediatric Tularemia: A Case Series With a Waterborne Cluster

BACKGROUND: Tularemia may be difficult to recognize in children because of its nonspecific presentation. We aimed to describe the epidemiologic, clinical and diagnostic characteristics of pediatric tularemia in Amasya, Türkiye, emphasizing water exposure, diagnostic delay and public health response. METHODS: We retrospectively reviewed 8 patients <18 years of age diagnosed with tularemia between January 2021 and January 2026. Demographic data, epidemiologic exposures, clinical and laboratory findings, diagnostic timelines, treatment, complications and outcomes were obtained from medical records. RESULTS: The median age was 12.1 years (range: 7-16 years), and 4 patients were female. All reported consumption of untreated spring or fountain water; 7 (87.5%) reported similar illness in the surrounding community, and 7 (87.5%) initially presented to the emergency department. Five patients had glandular, 2 oropharyngeal and 1 typhoidal tularemia. The median interval from symptom onset to first healthcare presentation was 4.5 days, and the median interval from symptom onset to submission of the initial serum sample for tularemia serologic testing was 17 days. All patients had received antibiotics before tularemia was confirmed. Two developed lymph node abscesses, 1 required incision and drainage, and 1 relapsed. Five temporally clustered cases shared exposure to the implicated source. Microbiologic culture of the implicated source yielded Francisella tularensis, and the source was subsequently closed to public use. CONCLUSION: In endemic areas, the actual source of drinking water should be specifically assessed regardless of residence. Tularemia should remain in the differential diagnosis even without cervical lymphadenopathy. Early recognition of clustered cases and timely public health communication may reduce diagnostic delay and facilitate source-control measures.