Page 84 - JSOM Fall 2024

FIGURE 2 Map of INDOPACOM region showing the prevalence of typhoid cases.

(Source: Centers for Disease Control and Prevention.)
with no significant history, a positive test in a symptomatic operating in the INDOPACOM region should be keenly aware
patient should be considered an acute typhoid infection. 2 of the signs, symptoms, and initial management of this dis-
ease process. The greatest countermeasure to typhoid is prede-
The current criteria by the International Encephalitis Consor- ployment vaccination. Unit immunization screening should be
tium establish encephalitis as a clinical diagnosis, with labora- performed prior to deployment to the INDOPACOM region
tory evaluation more supportive of diagnosis than definitive, (Box 1), with risk mitigation measures for unvaccinated in-
instead helping to identify potential underlying causes and dividuals, including possible removal unless critically needed
complications (Box 3). 1,10 The authors note that lumbar punc- for a mission, limited interactions with the local populace, and
ture should not delay empiric therapy, which should be con- vector barriers to help prevent transmission. While presenta-
tinued even if initial CSF samples are negative, recommending tions trigger a broad differential diagnosis, aggressive broad
repeat testing from a new sample 3–7 days later. 1,11 empiric therapy is warranted in cases of suspected typhoid,
with immediate evacuation to specialty facilities. This case
BOX 3 Criteria for Clinical Diagnosis of Encephalitis highlights the need for effective medical planning with proper
Major criteria (both required): facilities for definitive care. This includes planned pathways of
• Decreased level of consciousness, personality change, or care involving local facilities for rare but emergent cases such
psychiatric manifestations >24hr as infectious diseases and vascular, neurologic, and cardiopul-
• No significant alternative diagnosis to explain the monary conditions.
presentation
Minor criteria (presence of >2 in addition to both major criteria
above): BOX 4 Immunizations Required for INDOPACOM Deployment
• Fever (>38°C) Required for all personnel Required for certain personnel
• Seizure (new onset)
• Focal neurologic findings (new onset) • Hepatitis A • Anthrax* †
• CSF WBC count >5/mL • Hepatitis B • Influenza ‡
• Acute abnormality on brain MRI • MMR • Japanese encephalitis
†
• Abnormal EEG consistent with acute neurologic dysfunction • Polio • Meningococcal
• Tdap • Pneumococcal †
CSF = cerebrospinal fluid; EEG = electroencephalogram; WBC = white • Varicella • Rabies †
blood cell count. • Tick-borne encephalitis †
• Typhoid*
• Yellow fever †
Encephalitis treatment prioritizes immediate empiric IV ad-
ministration of broad pharmacotherapy, including antibiotics *Required for high-risk Korea, III Marine Expeditionary Force and
Operations Forces.
and antivirals for the most common causes, with consider- † Required for high-risk exposure.
ations for antifungals if there is suspicion of fungal infection. ‡ Required for all Air Force, Army Special Operations Forces, Navy,
While ceftriaxone is ideal, especially with availability for most and Marine Corps deployed to Japan or Korea for 30 or more consec-
military units, the addition of vancomycin should be consid- utive days; recommended for all others.
ered for coverage of penicillin-resistant Streptococcus bacte- Source: health.mil
ria. 1,2,6,7,10 Acyclovir should be added to cover herpes simplex MMR = measles, mumps, rubella; Tdap = tetanus, diphtheria, acellular
virus, given that it is the most common cause of encephalitis. pertussis.
3
Literature recommends adding a high dose of corticosteroid,
primarily dexamethasone, for treatment of inflammation. Sup- Conclusion
portive care includes fluid resuscitation, antipyretics, benzodi- Typhoid encephalitis is a rare but potentially fatal disease
azepines, and antiepileptics as needed for seizures. with regional predominance in operational areas, including
Southeast Asia. Laboratory evaluation can confirm suspi-
Given the prevalence of typhoid and its potentially disas- cion, but clinicians should be aware of clinical diagnosis and
trous complications such as encephalitis, military clinicians emergent need for empiric treatment, even in the prehospital

82 | JSOM Volume 24, Edition 3 / Fall 2024