Page 137 - JSOM Summer 2018

TABLE 1 Cholinergic Toxidrome (“DUMBELLS”) Lessons Learned
D iarrhea • The ADVISSOR system allowed for direct access to spe-
U rination cialty physicians within minutes.
M iosis • Use of email communication with images of the patient
B radycardia is especially valuable in developing differential diagno-
E mesis ses when the chief complaint is dermatologic in nature
L acrimation or in settings where images help convey physical exam
L ethargy more accurately.
S alivation • Network resources should be available to facilitate
still or video image-supported telemedicine in austere
While each biologic agent has its distinct clinical presentation, settings.
fever and malaise are common manifestations in all the agents • In presentation of nonspecific symptoms and pro-
above with the exception of botulism, where cranial nerve dys- dromes, monitoring over time and follow-up are vital
function is apparent. These symptoms progress and worsen, to ensure the absence of further disease progression or
usually within days. The patients’ presentations were not con- propagation within the unit.
sistent with these diagnoses.
Disclaimer
With the exception of cutaneous anthrax where necrotic pain- The views expressed are those of the author(s) and do not re-
less ulcers with overlying eschar is present (Figure 5) and in flect the official policy or position of the US Army Medical De-
2
smallpox where the characteristic synchronous progression of partment, Department of the Army, Department of Defense,
papules to pustules to scabs is observed (Figure 6), general- or the US Government.
1
ized papular and pustular eruptions are not representative of
biologic agents. Disclosures
The authors have nothing to disclose.
FIGURE 5 Painless depressed eschar seen in cutaneous anthrax.
Author Contributions
SB and JM were involved in patient care, conceived of the pre-
sented idea, and ensured the authenticity of the case report.
HL took the lead in writing the manuscript with input from
all authors. JM ensured the toxicology section provided crit-
ical feedback and ensured the accuracy of the toxicology sec-
tion. HY reviewed the manuscript for accuracy with respect to
infectious disease. DP, WV, and DF reviewed the manuscript
with respect to critical care. All authors contributed to the fi-
nal version of the manuscript. JP supervised the project.

References
1. Centers for Disease Control and Prevention. Smallpox. https://
www.cdc.gov/smallpox/symptoms/index.html. Accessed 26
March 2018.
FIGURE 6 Sharply raised, pustular rash, seen on day 6 of smallpox. 2. Wikimedia Commons contributors. Cutaneous anthrax le-
sion on the neck. PHIL 1934 lores.jpg, Wikimedia Commons,
the free media repository, https://commons.wikimedia.org/w
/index.php?title=File:Cutaneous_anthrax_lesion_on_the
_neck._PHIL_1934_lores.jpg&oldid=204326307. Accessed 27
March 2018.
3. Fuenfer MM, Creamer KM. Pediatric Surgery and Medicine
for Hostile Environments. Chapter 38: Chemical, biological,
radiological, nuclear and explosive injuries. Washington, DC:
Government Printing Office; 2013.
4. Ramesh AC, Kumar S. Triage, monitoring, and treatment of
mass casualty events involving chemical, biological, radiolog-
ical, or nuclear agents. J Pharmacy Bioallied Sci. 2010;2(3):
239–247.
5. Lenhart MK. Medical Aspects of Chemical Warfare. Washing-
ton, DC: Department of the Army, USA; 2008.
Even after the exclusion of CBRNE injuries, endemic infec- 6. San Diego County, California. Image of the effects of a blister
tions in this area, including viral hemorrhagic fever, malaria, agent on skin. https://commons.wikimedia.org/wiki/File:Blister
trypanosomiasis, and schistosomiasis, are important diagno- -arm.jpg. Accessed 2 April 2018.
ses to consider, in regard to both isolation precautions and
the potential for morbidity from clinical progression. Travelers
and clinicians are encouraged to use the Centers for Disease
Control and Prevention resources before departure to endemic
regions.

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