Page 88 - Journal of Special Operations Medicine - Winter 2015

to mosquitoes during the deployment, but denied use of fever and adequate intravenous fluid resuscitation. At
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bed nets and of DEET or other insect repellent, despite this point, it became apparent that the admitting physi-
knowing that he had been bitten or stung by multiple cian had limited familiarity with the diagnosis or man-
biting and stinging insects. He thought that rodents and agement of tropical infectious disease, and would be
pests were well controlled, but endorsed the presence leaning heavily on the battalion medical team to provide
of fleas in his living area. He denied swimming in fresh clinical guidance in this area.
water sources, but did swim and bathe in the ocean at
times. He admitted to frequent exposure to livestock, The Soldier was subsequently admitted to a general
particularly cattle and goats, causing us to consider bru- medicine ward, with the battalion medical team provid-
cellosis or Q fever. He denied known animal bites or ing consultation. Later that evening, the Soldier’s fever
envenomation. He denied any type of sexual contact defervesced and did not return. However, his platelet
while deployed. His past medical and surgical history counts began to decline further following fever defer-
were unremarkable. He denied any medication or di- vescence. This clinical finding was supportive of a di-
etary supplement use, including no use of malarial che- agnosis of dengue fever, but suggested an unsettling
moprophylaxis while deployed despite admitting that it progression potentially toward severe dengue or dengue
was readily available to him. He reported being an ac- hemorrhagic fever. The Soldier remained on bed rest
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tive daily smoker. with intravenous fluids while preparations were made
for blood component therapy if hemorrhagic compli-
Since the Soldier had been deployed for a prolonged pe- cations developed (Figure 1). We were fortunate that
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riod, we knew that we would need to consider infec- complications did not develop. The Soldier’s platelet
tious causes with both long (over 3 weeks) and shorter count reached a nadir of 35,000/μL at 48 hours into
incubation periods. The combination of fever and the admission, and rebounded rapidly to normal in the
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thrombocytopenia is always concerning, even in the subsequent 48 hours. Adequate resuscitation was given,
most advanced medical centers, particularly in a young but overresuscitation could dilute platelets further. The
person. The current process appeared to be acute, and patient was stable for discharge after 72 hours of admis-
foremost in our minds were mosquito-borne illnesses sion and returned home to continue to convalesce with
such as malaria, dengue fever, and chikungunya fever, a clinical diagnosis of dengue fever.
particularly given the Soldier’s report of noncompliance
with many preventive measures. Other considerations Thick and thin blood smears for malaria obtained dur-
3
included leptospirosis, rickettsial disease such as scrub ing the initial febrile episode showed no evidence of
typhus, and typhoid fever, because of his extensive ex- parasitemia, as did two additional smears at 12 and
posure history. Typhoid fever was considered less likely 24 hours later. The Soldier did complete a 3-day em-
given the patient’s prior vaccinations. The confirmation piric course of treatment of uncomplicated malaria, as
of a normal chest radiograph at least provided some re- the third and final dose was received 48 hours into the
assurance that the Soldier was likely not actively trans- admission. All other empiric antimicrobial therapies
mitting tuberculosis during movement. were stopped at 48 hours into the admission. Dengue
immunoglobulin M levels drawn on the day of admis-
After discussion with the laboratory, we realized that sion ultimately returned significantly elevated, but these
diagnostic testing was going to be difficult in this small, results were not available until 2 weeks following the
overseas US medical treatment facility. Serologic testing initial admission. Dengue serotype identification was
for dengue, rickettsial disease, and leptospirosis would not provided. All other diagnostic testing for infectious
likely take a week or more to return. Rapid diagnostic disease was ultimately unremarkable, but results were
testing for malaria was not available at this location. not available until well after the Soldier had been dis-
Furthermore, it was not clear that the laboratory tech- charged from hospitalization.
nicians were confident in their ability to review thick
and thin smears for malaria. We recognized that the Sol- This case became notable for us because it highlighted
dier was acutely ill and had the potential to decompen- two primary lessons, among others, that we believe are
sate rapidly; thus, we recommended that the admitting often overlooked. First, we should remember that even
physician treat aggressively with antimicrobials while in time of war, Special Operations medicine is more than
awaiting laboratory review. We recommended empiric trauma medicine. It is inevitable that trauma manage-
treatment for uncomplicated, undifferentiated malaria ment will be the focus of medical training in prepara-
with atovaquone-proguanil, in addition to an empiric tion for combat. However, we were reminded here that
course of ceftriaxone and doxycycline for coverage of disease/nonbattle injury still takes Soldiers out of the
leptospirosis, rickettsial disease, and typhoid fever. fight and can strain medical resources. It is imperative
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Dengue fever was considered very possible and we rec- that SOF medical personnel remain competent not only
ommended supportive care measures with control of in the recognition and treatment of illnesses endemic

76 Journal of Special Operations Medicine Volume 15, Edition 4/Winter 2015