Page 114 - 2020 JSOM Winter

Austere Surgical Team Management of an Unusual Tropical Disease

A Case Study in East Africa

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Michael-Flynn Cullen, MD *; Michael Stephens ; Erick Thronson ;
Daniel Brillhart, MD ; Julie Rizzo, MD 5
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ABSTRACT
Buruli ulcer caused by Mycobacterium ulcerans is a rare infec- extremities, with no trunk or genital involvement (Figures 1
tious skin disease affecting patients in sub-Saharan Africa as and 2). While admitted to a local hospital, he had been treated
well as in parts of Australia and Asia. These ulcers can cause with honey-impregnated dressings and oral β-lactamase–
significant morbidity affecting patients’ functional, psycholog- resistant flucloxacillin without improvement.
ical, and social states, particularly in resource-limited environ-
ments. We present the case of a patient with Buruli ulcers and Our initial assessment revealed an undernourished, ill- appearing
discuss treatment options for Special Operations medical pro- child with multiple painful, purulent ulcers to his face and ex-
fessionals to consider in the austere management of this and tremities measuring between 1 and 13cm, in addition to one
similar diseases. Treatment for Buruli ulcers requires a multi- 3cm bulla to his left posterior knee. The ulcers did not extend
disciplinary approach that includes a strict antibiotic regimen, through the fascia, though lesions did affect the skin overly-
meticulous wound care with a particular focus on contracture ing both knee joints. He was mildly tachycardic and febrile to
prevention, possible surgical intervention, and rehabilitation. 102°F. The remainder of his physical examination was notable
Rehabilitation is a vital part of the treatment plan that may for lower extremity contractures at both knees and the absence
greatly improve quality of life and psychological health. of lymphadenopathy. Successive expeditionary resuscitative
surgical teams (ERSTs) managed this patient in partnership
Keywords: Buruli ulcer; ulcers; Mycobacterium ulcerans; in- with an African Union clinic over a course of 1 year. Electronic
fectious skin disease consultation to American infectious disease and dermatology
services greatly aided in the management of this patient.

Introduction Medical Management
Buruli ulcer caused by M. ulcerans is a rare infectious skin At initial presentation, the diagnosis was unclear, but we sus-
disease affecting patients in sub-Saharan Africa and parts of pected a primary ulcerative process, either infectious or auto-
Australia and Asia. These ulcers can cause significant mor- immune, with a superimposed secondary bacterial infection of
bidity impacting patients’ functional, psychological, and so- the ulcers. Given the extensive purulence and necrotic tissue,
cial states, particularly in resource-limited environments. We we elected to sedate the patient for surgical debridement of the
present a patient with Buruli ulcers and discuss treatment and wounds. We gave broad-spectrum intravenous antibiotics with
rehabilitation. weight-based doses of vancomycin and ertapenem, followed
by a course of oral clindamycin. At his follow-up 1 week later,
the secondary bacterial infection was resolved with no puru-
Case Presentation lence or surrounding erythema, leaving behind only the pri-
A previously healthy 9-year-old boy presented to a military mary ulcerative process.
medical clinic in the Horn of Africa with months of fever
and painful ulcerations to his face and extremities. Initially, We used the US military’s online telehealth consultation sys-
he had developed a progressively enlarging ulcer to his left tem, HELP/PATH, to consult dermatology and infectious
infraorbital area, followed by similar ulcerations to all four disease specialists. They diagnosed Buruli ulcers caused by
*Correspondence to micull.lagozzino@gmail.com
1 MAJ Cullen is assistant professor of physical medicine and rehabilitation (nontenured), Uniformed Services University of Health Sciences,
School of Medicine, Bethesda, MD; ERST-6 Expeditionary Resuscitative Surgical Team; Special Operations Command Africa working for Special
Operations Task Force East Africa. SO2 Stephens is affiliated with Navy Special Warfare Group 2; ERST-6 Expeditionary Resuscitative Surgical
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Team; Special Operations Command Africa working for Special Operations Task Force East Africa. CPT Thronson is affiliated with ERST-6 Ex-
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peditionary Resuscitative Surgical Team; Special Operations Command Africa working for Special Operations Task Force East Africa. MAJ(P)
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Brillhart is associate program director, Emergency Medicine Residency Program, Carl R Darnall Army Medical Center (CRDAMC), Ft Hood,
TX; assistant professor of emergency medicine, Robbins College of Health and Human Sciences, Baylor University, Waco, TX; and adjunct as-
sistant professor of emergency medicine, College of Medicine, Texas A&M University, Bryan, TX; ERST-6 Expeditionary Resuscitative Surgical
Team; Special Operations Command Africa working for Special Operations Task Force East Africa. LTC Rizzo is affiliated with the US Army
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Institute of Surgical Research, Fort Sam Houston, TX; and Uniformed Services University of Health Sciences, Bethesda, MD.
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