Page 22 - JSOM Winter 2019

for Special Operations trainee populations. Previous studies peripherally inserted central catheter line. On outpatient
4,6
have found that trainees throughout the Special Operations follow-up 2 weeks later, the patient reported full resolution
community exhibit double-digit losses in body weight, gener- of his cutaneous symptoms and edema, and later successfully
ating corresponding reductions in immunity and increases in completed BUD/S training.
rates of pneumonia and SSTIs. 19–21 Furthermore, extreme en-
vironmental exposure can likewise further jeopardize immune Discussion
response. 22,23 Among BUD/S candidates, consistent marine
exposure, limited sleep, and increased stress can significantly S algae is a unique and deadly bacterium that has been impli-
deplete immune function with resulting infections, as docu- cated in seawater infections throughout the world. The varying
mented with previous infection outbreaks of Coccidioides im- manifestations of S algae can range from a V vulnificus mimic
mitis. The following case demonstrates a novel presentation with severe necrotizing fasciitis to lesser SSTIs to nonspecific
24
of S algae in a BUD/S candidate. GI symptoms, making diagnosis more challenging. Limited lit-
erature and inconsistent treatment options further complicate
recognition and management. Healthcare providers should be
Case Presentation
keenly aware of the most common presentations of SSTI in the
A 24-year-old male BUD/S training candidate presented to the lower extremities, especially through open wounds and ulcers,
emergency department (ED) complaining of a 3-day history of while considering that S algae infections are not confined to
significant swelling throughout his entire lower body below the marine environment. This triple threat of immune suppres-
the hips, to include his genitals and both bilateral lower ex- sion, mucosal entry points through poor-healing wounds, and
tremities, scattered with multiple large abrasions. The patient environmental exposures holds particular importance for seri-
had first noticed the swelling began around his ankles midway ous polymicrobial infections in military members in especially
through “Hell Week” but initially did not seek medical care stressful training environments such as the BUD/S course.
for concern of being involuntarily withdrawn from the course.
The morning prior to presentation, he discovered the swell- Conclusion
ing had spread proximally with additional left knee pain that
severely restricted ambulation. He complained of increasing Special Operations trainees represent a unique population of
pain from the abrasions throughout his hips, lower abdomen, physically and psychologically stressed individuals with proven
buttocks, and specifically genitals, which caused his urination risk of immunocompromised status. Similarly, prolonged en-
to be extremely painful and difficult. He endorsed increased vironmental exposures under grueling conditions can expose
dyspnea and fatigue but attributed this to the intensity and them to bacterial infection and illness, including severe celluli-
length of physical training with decreased sleep. tis. When considering infectious causes for these trainees after
exposure to marine environments, this case demonstrates that
Upon triage at the ED, he was found to be mildly tachycar- providers should consider polymicrobial infections and broad
dic but otherwise had normal vital signs to include his tem- etiologies beyond common bacteria, including S algae, when
perature. Physical examination confirmed widespread edema selecting empiric antibiotics.
spreading distally from his waistline throughout the lower
extremities, with additional large weeping wounds on the Disclosure
superior thighs along the medial and lateral aspects, each ex- The authors have nothing to disclose.
quisitely tender to light touch. Genital exam showed similar
significant chaffing and swelling of the penis and scrotum. Re- References
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protein (4.54mg/dL), creatine kinase (714U/L), and lactate 2. Khashe S, Janda JM. Biochemical and pathogenic properties of
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limits, including complete blood count, liver function testing, 3. Sharma KK, Kalawat U. Emerging Infections: Shewanella–a series
lipase levels, and remaining metabolic panel values. Left knee of five cases. J Lab Physicians. 2010;2(2):61–65.
radiographs taken revealed only a small joint effusion and 4. Srinivas J, Pillai M, Vinod V, et al. Skin and soft tissue infections
diffuse subcutaneous edema without evidence of fracture or due to Shewanella algae—an emerging pathogen. J Clin Diagn
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subcutaneous air. The patient was given 2L of normal saline 5. Myung DS, Jung YS, Kang SJ, et al. Primary Shewanella algae
and started on an empiric antibiotic regimen of 750mg levo- bacteremia mimicking vibrio septicemia. J Korean Med Sci. 2009;
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20 | JSOM Volume 19, Edition 4 / Winter 2019