Page 81 - JSOM Fall 2024

An Ongoing Series

Prolonged Care for Presumed Typhoid Encephalitis in Indonesia

Ileene Berrios, MPAS, PA-C ; Brandon M. Carius, DSc, PA-C *;
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Nathan A. Vaughn ; Logan Dobbe, MD 4
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ABSTRACT
Despite advancements in military medical treatment and evac- Case Presentation
uation, soldiers in austere environments remain vulnerable to
disease and non-battle injury and may face prolonged evac- In the early morning, a 19-year-old active-duty Soldier pre-
uation before receiving definitive care. In particular, arrang- sented at the battalion aid station in the region of Sumatra, In-
ing care for a soldier presenting with a conditions that has a donesia, complaining of bilateral shoulder pain. He appeared
wide differential diagnosis, such as acute altered mental status to have altered mental status and lost consciousness when the
(AMS), can be especially challenging. We highlight the case of medics laid him on the litter stand. Initial vital signs included
an otherwise young, healthy U.S. Soldier serving in Indonesia, a blood pressure of 100/60mmHg, pulse rate of 100 beats per
who presented with acute AMS concerning for undifferentiated minute, respiratory rate of 18 breaths per minute, blood oxy-
infection. Subsequent workup at the receiving hospital follow- genation of 98% on room air, and core temperature of 103°F.
ing evacuation revealed Salmonella enterica infection, more This presentation raised concerns for undifferentiated shock,
commonly known as typhoid. However, even with clinical find- including sepsis or heat stroke, and prompted fluid resuscita-
ings of typhoid encephalitis and initiation of empiric treatment, tion with intravenous (IV) administration of 1L of saline and
medical care proved challenging in the resource-limited local 1g of acetaminophen. External cooling with ice sheets was also
facilities, despite multiple escalations of care. Ultimately, the initiated.
patient was evacuated to a tertiary facility in Singapore, where
his condition improved, and 4 days after initial presentation, After some time, the patient regained consciousness and
the patient had no definitive findings of infections on lumbar complained of heaviness throughout his body. Neurological
puncture. This case not only highlights the threat of typhoid evaluation found motor strength of 3 out of 5 throughout all
and other infectious diseases in modern operations but also the extremities, inability to distinguish light and sharp touch on
challenges of suboptimal medical care in both the prehospital sensory testing, and gross ataxia. This presentation prompted
and hospital settings when utilizing host nation facilities. concern for a wide differential diagnosis (Box 1); however,
chief among them were meningitis and encephalitis. The med-
ical team administered 2g of IV ceftriaxone along with 40mg
Keywords: altered mental status; prolonged casualty care;
MEDEVAC; infectious diseases; optimal medical care; of dexamethasone (patient weight estimated at 100kg) for
encephalitis; PCC empiric coverage. Heat stroke was determined unlikely given
the patient had not been performing any exertional activities
prior to his morning presentation. Recreational drug intox-
ication was not suspected. The patient had no findings sus-
Introduction
picious for an envenomation from local wildlife, significant
Encephalitis is brain inflammation with associated neurologic cardiovascular history or recent injury to suggest a cerebro-
dysfunction, but often can present in hybrid forms including vascular accident or hemorrhage, or any history suspicious for
meningoencephalitis or encephalomyelitis. While clinical find- metabolic disease. Interviews with the patient’s peers revealed
1
ings are sufficient for diagnosis, treatment can prove difficult that the patient participated in daily excursions to meet with
in prehospital and even hospital settings abroad. Military cli- local nationals, as well as daily interactions with partially
nicians should be aware of regional infectious disease patterns, domesticated animals. Notably, despite the requirements for
such as the prevalence of Salmonella enterica serotypes Typhi Indo-Pacific Command (INDOPACOM) deployment, he had
and Paratyphi (better known as typhoid) in Southeast Asia, to not received several vaccinations, including typhoid and Japa-
2
help understand underlying causes of encephalitis. The follow- nese encephalitis vaccines, because of religious deferment.
ing case highlights the difficulties in diagnosis, management,
and escalation of care for typhoid encephalitis for military cli- Given limited diagnostic tools in a forward environment, the
nicians in the operational environment. patient was transferred to a local hospital in Tanjung Baru
*Correspondence to brandon.m.carius.mil@health.mil
1 CPT Ileene Berrios, MAJ Brandon M. Carius, and CPT Logan Dobbe are affiliated with Madigan Army Medical Center, Joint Base Lewis-
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McChord, WA. SSG Nathan A. Vaughn is affiliated with HHC, 1-229 CAB, Joint Base Lewis-McChord, WA.
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