Page 13 - Journal of Special Operations Medicine - Winter 2015

Hypolipidemia in a Special Operations Candidate

Case Report and Review of the Literature

Available at the SOMA Symposium
14-16 Dec 2015 • San Marcos, TX Jonathan E. Strain, MD; John A. Vigilante, MD; Nicholas W. DiGeorge, DO
___________
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ABSTRACT
Background: A 19-year-old male military recruit who was found to have hypolipidemia. Analysis of the disease
presented for a screening physical for US Naval Special suggests there is minimal increased risk in diving and
Warfare Duty was found to have hypolipidemia. Medi- Special Operations for patients who are likely hetero-
cal history revealed mildly increased frequency of bowel zygous, are asymptomatic, and have a negative workup
movements, but was otherwise unremarkable. His pre- for potential complications from the disease.
sentation was most consistent with heterozygous familial
hypobetalipoproteinemia (FHBL), and the patient was
cleared for Special Operations duty. Methods: A litera- Case Presentation
ture search was conducted using PubMed/ MEDLINE. A 19-year-old male military recruit presented for a
Keywords included familial hypobetalipoproteinemia, screening examination for Naval Special Warfare duty.
heterozygous familial hypobetalipoproteinemia, abetali- He noted mildly increased frequency of bowel move-
poproteinemia, hypolipidemia, diving, special opera- ments. His history and physical examination findings
tions, and military. Results that included cases of familial were otherwise unremarkable. He denied other gastroin-
hypobetalipoproteinemia were included. Results: Re- testinal symptoms, changes in vision, and changes in bal-
view of the literature reveals that FHBL is a genetic dis- ance or neurologic functioning. His family history was
order frequently, but not always, due to a mutation in notable for a paternal aunt and uncle who were twins
Be prepared to the apo lipoprotein B (apoB) gene. Those with the condi- and who both had mildly elevated liver enzymes. They
apply what you know. tion should be screened for ophthalmologic, neurologic, were asymptomatic. Further information was not avail-
and gastrointestinal complications. Analysis of the dis- able on the aunt and uncle, or on the lipid levels of the
ease, as well as the absence of reported cases of FHBL patient’s mother and father. As part of his screening labo-
in diving and Special Operations, suggest there is mini- ratory tests, a lipid panel was obtained. He was found to
mal increased risk in diving and Special Operations for have severely decreased levels of total cholesterol (60mg/
patients who are likely heterozygous, are asymptomatic, dL [reference range, 0–200mg/dL]), low-density lipo-
The easy-to-carry, pocket-sized ATP-P Handbook and have a negative workup for potential complications protein (LDL) (8mg/dL [reference range, 0–130mg/dL]),
Be prepared when an emergency occurs! With the is perfect for training, reference, or field use. from the disease. Conclusion: Individuals with presumed and triglycerides (71mg/dL [reference range, 0–150mg/
Journal of Special Operations Medicine’s Advanced Harness the power of up-to-date resources: or proven heterozygous FHBL seeking clearance for Spe- dL]). This prompted further evaluation, which revealed
Tactical Paramedic Protocols (ATP-P) Handbook you’ll • Tactical trauma and medical emergency protocols cial Operations duty should be given precautions, un- a significantly decreased apolipoprotein B level (less than
dergo careful questioning for history of disease-specific
be prepared with current and robust protocols • Recommended Drug List (RDL) complications, and should have a baseline evaluation. If 30mg/dL [reference range, 52–109mg/dL]). He was thus
diagnosed with hypobetalipoproteinemia (HBL).
in a handy reference. Capture and utilize the same w Side-effects / adverse effects / negative, it seems reasonable to clear the patient for Spe-
valuable medical knowledge used to ensure that contraindications / warnings cial Operations and diving. Genetic testing was not feasible during his short time in
Special Operations Advanced Tactical Paramedics w Adult and pediatric dosages boot camp, nor was it thought that it was acutely nec-
are able to provide the most highly skilled medical w Relevant protocol correlation Keywords: hypobetalipoproteinemia, familial; hypobetalipo­ essary. Given his lack of symptoms, normal childhood
care in the field. • Canine TCCC proteinemia, heterozygous familial; abetalipoproteinemia; development, and the workup initiated (fat-soluble vita-
min levels, liver enzyme levels, peripheral blood smear,
hypolipidemia; diving; Special Operations; military
In addition to the SOF medics, the ATP-P Handbook • Practical reference charts featuring: fecal fat content, liver ultrasound, and retinal examina-
is ideal for TEMS components of DoJ, Border Patrol, w Burn and Nerve tion), it was thought that his history and phenotype were
Homeland Security, SWAT, and any other paramedic w Military Acute Concussion Evaluation (MACE) Introduction strongly suggestive of a diagnosis of heterozygous FHBL.
professionals who perform in the unconventional w Prehospital Combat Medic/ A 19-year-old male military recruit who presented for a
environment. Corpsman Algorithm (CMA) screening physical for US Naval Special Warfare Duty Lipid levels meeting criteria for HBL are not uncom-
mon, with some reports suggesting the prevalence of the

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