Page 127 - JSOM Summer 2019

Consultation Recommendations water from approved sources should be emphasized in
medical threat briefs.
Asynchronous Telemedicine • How did this infection occur? It is crucial to obtain
(With the Army Teleconsultation Program) a detailed history of where food and water were con-
The initial response from the consultant commented on a very sumed. The incubation period of S. paratyphi is 6 to 30
broad differential with concerns for possible musculoskeletal days. If no significant travel history or food or water
issues, central nervous system involvement (i.e., meningitis), consumption from unapproved sources occurred before
septic arthritis, or tick-borne illness. The communication the deployment, then it is likely that the infection oc-
stressed the importance for him to be evaluated by a doctor curred during this deployment to West Africa. If the pa-
and taken to a local hospital immediately. Questions posed tient only consumed food and water from the approved
were: sources, there may be concern that a food handler is an
asymptomatic carrier. Preventive medicine should also
• How long will it take to get him to a hospital? be involved in the discussions. As of fall 2018, there
• Any issues with his neck (rigidity or tenderness)? have been no additional reports of similar illnesses from
• Any rashes anywhere on his body? this area of operation.
• Which joints are involved? • Once an index case is identified, close monitoring should
• What kind of antibiotics do you have, particularly IV be conducted for any illnesses that could be consistent
formulations? with S. paratyphi infection. It should also be noted that
the presence of malaria can increase an individual’s risk
The consultant requested additional labs. Unfortunately, the for nontyphoidal Salmonella (NTS). 3
local lab was closed for the next 36 hours. After this informa- • NTS remains a concern for deployed Soldiers to Africa
tion was relayed to the consulting physician, the recommen- as there has been reports of increasing incidence of in-
dation was to send the patient immediately to the hospital for vasive NTS with resistance against ceftriaxone in sub-
additional evaluation by a physician. The consultant did note Saharan Africa. 4
that it did not necessarily have to be a US facility but that he
needed urgent assessment given the patient’s instability. How- Lessons Learned
ever, a visit to local facilities had previously found them to be • Fever in a deployed Soldier can be the only sign of a
unsuitable and unsafe for US Soldier care. life-threatening illness. Its evaluation and workup re-
main perplexing to healthcare providers. 5
Synchronous Telemedicine (With USARAF PA) • Even with the expeditionary experience of the US mili-
The USARAF PA consulted with the ADVISOR service, which tary and improved prevention of infectious diseases on
had the following recommendations: deployments, illness will still occur. 6
• Accurate and timely laboratory testing/results are often
• Continue aggressive volume resuscitation with IV fluids, necessary for making an appropriate diagnosis and in-
bolus as needed for fevers stituting appropriate therapy. Deployed persons to aus-
• Continue artemether/lumefantrine administration to to- tere locations should make every effort, when mission
tal 3-day course allows, to engage host nation and other local medical
• Based on formulary availability and concern for poten- services to provide the best possible care for US Services
tial salmonellosis in the setting of Gram-negative bac- members and affiliates. However, when doing so, they
teremia coinfection with malaria (with its associated should take into account the skill and training of the
increasing rates of resistance), Ertapenem 1g IV daily technicians being consulted.
until MEDEVAC available • Prolonged field care training must be stressed for med-
• Can start doxycycline 100mg PO twice daily while ical assets functioning in austere environments. Opera-
awaiting more definitive evaluation and diagnostics for tions in Africa and medical evacuations are susceptible
“Lyme disease positive testing.” to the “tyranny of distance.” Resuscitation, monitoring,
• Hold malaria chemoprophylaxis while on concomitant nursing care, and telemedicine skills were all necessary
artemether/lumefantrine because of concerns regarding for this patient.
QT prolongation. • Use of telemedicine technologies often requires training
before use. The existence of formal consultation scripts
helps with the consultation, but they must be rehearsed
Follow-Up
and practiced to be useful.
Teaching Points • Telemedicine should be used; however, there is room for
• Epidemiology: paratyphoid fever is a bacterial infection refinement. Medical providers with limited operational
caused by Salmonella enterica serotypes paratyphi A, experience and training may not fully understand the
paratyphi B, and paratyphi C (nontyphoidal Salmo- limitations imposed by distance or the limited resources
nella). The bacteria is only found in humans; transmis- in some austere operating environments. In particular,
sion is through ingestion of fecally contaminated food lack of diagnostic capabilities and limited formularies
or water or from an asymptomatic carrier. Paratyphoid make medical decision-making more challenging.
2
fever occurs worldwide primarily in areas where sanita- • Given the complexity of this case, multiple telemed-
tion is substandard (i.e., international travel to high-risk icine consultations occurred with different “remote
regions such as Africa and Southeast Asia). 2 experts.” The military needs to develop solutions that
• Paratyphoid fever can be prevented through the con- allow a “shared mental model” to be formed between
sumption of safe food and water and good handwashing all consultants/caregivers or for continuity of care for
hygiene. Frequent handwashing and the use of food and the remote expert. One option that might have been

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