Page 95 - Journal of Special Operations Medicine - Spring 2016

of this article, but we will briefly review those that de- first on the extremities and spreads to the trunk. Treat-
4
ployed military personnel may encounter and that might ment for RMSF, and most tick-borne diseases, is doxy-
require urgent treatment. Let’s talk a little about the cycline 100mg by mouth or IV twice daily for 10 days.
serious items on this the list that a Special Operations
medical clinician might encounter. Henoch-Schonlein purpura – This is an autoimmune
vasculitis that typically affects children. The classic pre-
sentation is a limping child with a rash and abdomi-
Category: The Patient Looks Sick nal pain. The petechial or purpura rash is often on the
and the Rash Is Palpable
buttocks or lower extremities. Most cases resolve spon-
Meningococcemia – The petechiae in this illness result taneously, but some children will require IV immuno-
from a life-threatening infection by the bacterium Neis- globulin and/or steroids.
seria meningitidis. This is an emergent condition that re-
quires immediate antibiotic treatment to prevent death. Category: Patient Is Febrile and
At-risk communities include military personnel, college the Petechiae Are Nonpalpable
students, or any groups living in close proximity. Vac- Thrombotic thrombocytopenic purpura (TTP) – This is
cination is helpful, but breakthrough cases do occur. a serious illness in which a patient’s platelets first become
Typically, the patient looks very unwell. There may be a too sticky and start forming tiny thrombi. This eventu-
prodrome of fever, confusion, headache, and neck stiff- ally consumes the platelets and leads to organ damage.
ness. The initial rash may be on the extremities and may The classic five features are fever, thrombocytopenia,
initially be macular, but once petechiae begin to appear, hemolytic anemia, neurologic issues, and renal failure.
5
the patient is going to be septic. Treatment needs to be Clinically, this may present as a confused patient with
implemented before the true source is known. Current altered mental status, a fever, and petechiae. Laboratory
adult guidelines recommend ceftriaxone 2g intrave- studies may show low platelet levels, anemia, renal fail-
nously (IV) every 12 hours or cefotaxime 2g IV every ure, and an elevated lactate dehydrogenase level. TTP
4–6 hours, plus vancomycin 15–20mg/kg IV every 8–12 can be due to an autoimmune condition or associated
hours. For adults over the age of 50 years, ampicillin 2g with other conditions like cancer and pregnancy. Treat-
IV every 4 hours is recommended. Patients will need ment includes fresh frozen plasma and emergent referral
2
to be in respiratory isolation to prevent spread of the for plasmapheresis. Covering with antibiotics is quite
5
infection. appropriate because it can be difficult to distinguish
from infectious causes. If encountered or suspected in
Infective endocarditis – In this infection, bacteria col- a deployed setting, the patient needs to be emergently
onize the heart, most often the heart valves. You are evacuated to a higher level of care. Somewhat counter-
unlikely to encounter this among deployed personnel. intuitively, you should not transfuse platelets because
At-risk populations include those who are immunosup- this will lead to more platelet clotting and end-organ
pressed, those with mechanical or prosthetic valves, and damage.
IV drug users. The presentation can be quite variable:
some people may appear to have a mild febrile illness Disseminated intravascular coagulation (DIC) – This is a
and some may look extremely sick. On history, inquire condition in which there is massive consumption of clot-
about risk factors and recent invasive procedures. On ting factors. This initially causes thrombus formation and
examination, look and listen carefully for new cardiac subsequently hemorrhage. This can be a consequence of
murmurs or heart failure. The skin should be inspected many severe disease processes, such as sepsis or hypother-
for tender, palpable petechiae, which are septic emboli mia, or of severe trauma. This is a key element of the
from the heart. Additional lesions can be seen in the triad of death after trauma: coagulopathy, hypothermia,
palms, fingernails, and eyes. If possible, try to take mul- and acidosis. This is a core principle of Tactical Com-
tiple blood cultures, but do not delay antibiotic treat- bat Casualty Care and all attempts should be made to
ment. Vancomycin 15–20mg/kg every 8–12 hours is an secure hemorrhage control, prevent hypothermia, and
appropriate initial therapy. 3 use minimal fluid resuscitation. If encountered, the clini-
cian should attempt to treat the underlying precipitating
Rocky Mountain spotted fever (RMSF; or other rick- process (i.e., treat the infection or stop the bleeding). If
ettsial infections) – RMSF is a tick-borne illness. The available, consider blood and blood product transfusion
tick carries the bacterium Rickettsia, which is endemic in a 1:1:1 ratio of packed red cells, platelets, and plasma. 6
to many areas of the United States, and is also com-
mon in Central and South America. Patients often pres- Purpura fulminans – This term refers to life-threaten-
ent with fever, headache, and petechiae. Not all patients ing purpura. There is usually a very serious antecedent
will present with the history of a tick bite or exposure. cause, such as sepsis, major trauma, burns, hypother-
Typically, the rash begins 2–4 days after fever and is seen mia, or malignancy. It should be treated like DIC.

Clinical Corner: Red Rash 79