Typhoidal: Gastrointestinal (GI) symptoms (diarrhea, pain) may be the most prominent feature. Systemic symptoms and signs are seen without lymphadenitis or cutaneous or mucosal lesions.
Ulceroglandular (70%-80%): A papule appears at the site of inoculation, most commonly at an inguinal or axillary site. The papule eventually becomes pustular and then ulcerates within a few days. An eschar may or may not form at the inoculation site. There is typically regional lymphadenopathy; the nodes may become fluctuant and rupture.
Oculoglandular (1%-5%): This form results in a purulent conjunctivitis. Small yellow nodules develop on the conjunctiva and ulcerate. They are usually unilateral. This may be accompanied by severe eyelid edema, vasculitis, and regional lymphadenitis.
Glandular (10%-15%): The glandular form is characterized by lymphadenopathy without cutaneous manifestations. It is identical to the ulceroglandular type except that a primary lesion cannot be identified.
Oropharyngeal: The oropharyngeal form can present with stomatitis or an exudative pharyngitis or tonsillitis. There may also be ulcers and cervical lymphadenopathy. It may present with cervical nodes resembling the “bull neck” of diphtheria.
Pneumonic: This form is rare in naturally acquired infection. Lymphohematogenous spread is the usual pathogenesis. Symptoms include dry cough, pleuritic chest pain, and dyspnea. Signs include rales and pleural friction rubs, pharyngitis, and hilar lymphadenitis along with other signs of systemic illness. X-ray or CT may show bronchial infiltrates, pleural effusions, and hilar lymphadenopathy.
Septicemic: This is the most severe form of tularemia. In addition to the GI presentation of the typhoidal form, central nervous system symptoms such as confusion or coma may occur.