Page 87 - Journal of Special Operations Medicine - Winter 2015

Fever and Thrombocytopenia in a Returning Soldier

John W. Downs, MD, MPH; Peter J. Biggane, BS

ABSTRACT

A case of fever and thrombocytopenia in a 33-year-old gastrointestinal symptoms. He did endorse diffuse my-
Special Forces Soldier with recent deployment to the algias without joint swelling or joint pain. He had noted
Philippines is discussed, as are differential diagnosis and no skin changes, including no rashes and no easy bruis-
initial medical management at an overseas, fixed US ing or bleeding. Our initial evaluation noted an oral
military medical treatment facility. The authors discuss temperature of 102.5°F and room air oxygen saturation
lessons learned that are applicable for Special Opera- greater than 93%. We then transported the Soldier to
tions Forces (SOF) medical providers and recommend the local overseas US military medical treatment facility
a renewed and continued emphasis on tropical medi- for further management, and conducted a more detailed
cine and infectious disease training for SOF medical examination there in the emergency department.
providers.
His general physical examination was notable for a well-
Keywords: dengue fever; military medicine; tropical medi­ developed young man who appeared visibly weak and
cine; travel medicine; fever of unknown origin lethargic. He coughed frequently during the examination
but was not in acute distress. His sclera and sublingual
glands did not appear jaundiced. His neck was supple
On a summer Friday afternoon, we were notified that without lymphadenopathy. His cardiac, pulmonary,
a 33-year-old Special Forces Soldier had apparently be- and abdominal examinations were unremarkable and
come ill while returning from an extended deployment included no apparent hepatosplenomegaly. A genitouri-
to a remote location in the Philippine Islands. We were nary examination found no adenopathy, no skin lesions,
provided limited information at the time other than to and no urethral discharge. His skin showed no evidence
expect his return to our home station in the next 24 of rash or petechiae or purpura. A “tourniquet test” is
hours, and that we should be prepared to receive him frequently performed as part of the diagnostic evaluation
from the airfield the following day. An abbreviated re- in patients returning from dengue endemic areas, but was
port noted that he had a febrile illness with lethargy but not performed here, as blood and platelet counts were
was clinically stable, and that a rapid diagnostic test for now readily accessible. A complete neurologic exami-
malaria was reportedly negative. With this limited infor- nation found no focal neurologic deficits; however, the
mation, our initial list of possible diagnoses was exten- patient’s responses to questions seemed to be delayed due
sive, and we began to prepare to receive the patient by to exhaustion. The initial laboratory analysis results in-
gathering as much additional information as we could. dicated mild hyponatremia (129mEq/L), mildly elevated
hepatic transaminase levels (aspartate aminotransferase,
On Saturday morning, we met the Soldier at the lo- 73U/L; alanine aminotransferase, 54U/L), and throm-
cal airfield. His general appearance was tired and dia- bocytopenia (platelet count, 70,000/μL). An admission
phoretic. He had clearly been uncomfortable en route chest radiograph was normal.
and had a recurrent, dry, forceful cough. A quick his-
tory revealed that the preceding 4 days had been filled While waiting for laboratory results to return, we ob-
with a near inability to function secondary to lethargy, tained additional travel and exposure history regarding
fevers, chills, and headache. The cough had only de- this recent deployment. The patient had been deployed
1
veloped in the last 24 hours. He denied any neck stiff- for 6 months and had not traveled off the remote island
ness, photophobia, or neurologic deficits, but reported to which he was assigned during this time. He endorsed
an almost overwhelming desire to sleep. He reported near-constant exposure to indigenous food and water
two episodes of vomiting in the last 4 days and noted over the preceding 6 months, but reported only one or
profound absence of appetite but otherwise denied any two mild cases of diarrhea. He noted frequent exposure

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