Military medicine
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We report a management strategy for disseminated Fusarium solani fungal infection in an adult 35% total body surface area burn patient with brain abscesses and concomitant pulmonic valve endocarditis resulting in the longest survival reported in a burn patient. Early in his hospital course, the patient was diagnosed with a Fusarium burn wound infection with concomitant fungemia and was treated with a prolonged course of intravenous (IV) antifungal monotherapy. Shortly thereafter, he developed focal neurologic deficits and was found to have brain abscesses on MRI. ⋯ However, this patient survived for approximately 1 year after diagnosis with treatment including source control via craniotomy and debridement coupled with prolonged courses of combination antifungal therapy (given the near pan-resistance of his fungal infection). Pharmacogenomic testing was utilized to establish the patient's metabolism of voriconazole and dosing adjusted accordingly to improve the efficacy of the combination therapy. To our knowledge, an adult burn patient surviving this length of time after Fusarium brain abscesses with disseminated infection has not been previously described.
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Birt-Hogg-Dube (BHD) is a rare cause of spontaneous pneumothorax caused by an autosomal-dominant mutation in the folliculin gene (FLCN). The syndrome can have widely variable presentations and is associated with recurrent pneumothorax, cystic lung disease, characteristic skin lesions, and renal tumors. Lung cysts have been described in over 80% of cases, and roughly 24 to 38% of patients have at least one pneumothorax and over 75% have multiple pneumothoraces. ⋯ This delay has clinical implications as screening for renal cancer is recommended in both the patient and affected family members. Increased recognition of this syndrome can lead to more patients receiving definitive treatment for their first pneumothorax, and being screened for renal cancers. We present a rare case of Birt-Hogg-Dubé with a never before described mutation in the FLCN gene, leading to spontaneous pneumothorax in an active duty male soldier.
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Cases of embedded unexploded ordnance are extremely rare and pose a risk to bystanders and health providers. A patient arrived at the Role 2 medical facility in the Turkish army, whose left arm was amputated due to a terrorist attack and major hemorrhages had been halted by clamping of the left subclavian artery and vein. ⋯ In these challenging cases, safety principles should be acknowledged. Highlighting the basic precautions is important for similar scenarios and increases awareness of the utmost importance.
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An 18-year-old male active duty US Army service member presented to the emergency department with a lower leg abscess in the region of a previously debrided methicillin-resistant Staphylococcus aureus abscess. After initial presentation, the patient became hypotensive, exhibited signs of renal failure, and developed a diffuse erythematous rash. Streptococcus pyogenes was grown from intraoperative cultures, and he was diagnosed with Streptococcal toxic shock syndrome (STSS). ⋯ Therefore, it is imperative for physicians to recognize systemic involvement of seemingly isolated extremity infections. We encourage a high index of suspicion in treating bacterial abscesses for possible complications, and close monitoring of patient status. This suspicion should be even higher during outbreaks of bacteria that can cause STSS, much like the patient presented here.
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Finger and hand injuries are among the most common musculoskeletal conditions presenting to emergency departments and primary care providers. Many rural and community hospitals may not have immediate access to an orthopedic surgeon on-site. Furthermore, military treatment facilities, both within the continental United States and in austere deployment environments, face similar challenges. Therefore, knowing how to treat basic finger and hand injuries is paramount for patient care. ⋯ Finger injuries are common in the military setting and presenting directly to an orthopedic surgeon does not appear the norm. Fingertip injuries, fractures within the hand, and finger dislocations can often be managed without the need for a subspecialist. By following simple guidelines with attention to "red flags," primary care providers can manage most of these injuries with short-term follow-up with orthopedics.