@article{ref1,
title="Missed sentinel case of naturally occurring pneumonic tularemia outbreak: lessons for detection of bioterrorism",
journal="Journal of the American Board of Family Practice",
year="2003",
author="Dembek, Zygmunt F. and Buckman, Ronald L. and Fowler, Stephanie K. and Hadler, James L.",
volume="16",
number="4",
pages="339-342",
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 &quot;tularemia,&quot; &quot;bioterrorism,&quot; &quot;index of suspicion,&quot; and &quot;sentinel case.&quot; RESULTS AND 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.<p /><p>Language: en</p>",
language="en",
issn="0893-8652",
doi="",
url="http://dx.doi.org/"
}