Spring 07 front cover - United States Special Operations Command

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Question 1:Using the primary lesion definitions outlined in your SOF medical handbook, how would you describe themorphology of these lesions prior to delivering their contents?Question 2:What is your differential diagnosis for these nodular draining lesions prior to probing? How about afteryou deliver the contents?122Journal of Special Operations Medicine Volume 8, Edition 2 / Spring 08
ANSWERSQuestion 1:Morphology: these lesions are non-fluctuant nodules that vary in size from 6mm to over 22mm in diameter.They are surrounded by mild to moderate erythema, and have a central puncta draining serosanguinous fluid.Question 2:Prior to making the obvious diagnosis based on the lesions’ content, your differential diagnosis should includecarbuncles and furncles, sebaceous cysts, skin malignancies, local insect bite reactions, and myiasis. Clues to help differentiatethis from a malignancy would be the number of lesions that developed, and their acute development. Sebaceouscysts also usually take much longer to develop. The local intense inflammation and pain also steers us awayfrom typical malignancies. Carbuncles and furuncles can look very similar to these lesions, and usually present in multiplepolymorphic stages, but you might expect more local tenderness and fluctuance to palpation, as well as lymphadenopathy.The serosanguinous drainage, when cultured, will often be sterile in the case of myiasis, whereas incarbuncles and furuncles the discharge is purulent and usually grows a staph species. Local reactions to insect bitesshould generally subside after several days to a week.MYIASISEPIDEMIOLOGYMyiasis, first described by Hope in 1840, 1 is the term used to describe the invasion of tissues and organs ofhumans and other animals by the larvae of flies of the order Diptera. Diptera are two-winged flies whose first stagelarvae require a warm-blooded animal as host for maturation. 2Dermatobia hominis, otherwise known as the human botfly, belongs to the family Cuterebridae. The botflyis endemic from central Mexico down through Central and South America, and can grow to 18mm in length. Theypopulate areas of forests and jungle, usually near rivers and streams or along coastal areas. 3 After it mates, the femalecatches a biting arthropod, such as a mosquito or tick, to act as a mechanical vector. It will hold the arthropod with itshind legs while it deposits 15 to 30 eggs on its abdomen. Multiple depositions may occur during the nine day life cycleof the female botfly, as up to 400 eggs are produced per female botfly. If an insect vector cannot be found, the femalebotfly may deposit its eggs on plant leaves instead.CLINICAL COURSEIn addition to humans, wild and domestic animals as well as birds can act as host to the fly’s development. Domesticcattle are a common target, which can have significant local economic impact. 4 Once the host comes into contactwith these plant leaves or has an egg carrying vector land on it, the eggs are deposited on the host animal. Theeggs increase in temperature due to contact with the warm blooded host, causing the eggs to hatch and resulting in afirst stage larva. The larva then enters the skin, anterior end first. It may enter through a hair follicle, a pore, or througha breach in the skin created by the aforementioned biting arthropod. This entire process usually takes less than 60 minutes,and sometimes in as little as 5 minutes. Initial penetration is usually not felt by the host. Within a day a smallpapule develops, gradually enlarging up to 15 to 20mm in diameter. 5The larva stays in the subcutaneous skin from four to 14 weeks. During this time it may grow to over 20mmin size, developing into an instar, or third-stage larva. At this point, the larva emerges from the skin, falls to the ground,pupates for 14 to 30 days in the soil, and emerges as a mature botfly, living for an additional two weeks. This entirelife cycle lasts approximately three to four months. 5,6The botfly larva itself has two curved oral hooks. These help it to grasp and tear tissue for the purposes of feeding,and are responsible for the searing and tearing feeling patients often describe with this infestation. The larva alsohas several rows of parallel concentric rows of posterior pointing spines that help it to remain anchored within the subcutaneoustissue. The larva breathes through a spiracular plate in its posterior end, resulting in the oft cited descriptionof bubbles appearing through the puncta or of movement of the column of fluid just inside the puncta. The fluiditself may be serosanguinous or even purulent an appearance, however it is not common for secondary bacterial infectionin these lesions, thus antibiotics are not usually required once the lesions are evacuated. 7TREATMENTMED Quiz 123
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Spring 08 Volume 8, Edition 2From t
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From the Command SurgeonWARNER D.
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Participants of the first USSOCOM C
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Component and TSOC Surgeons, and wh
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Jay Sourbeer, MDCAPT, USNCommand Su
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Ricardo Ong, MDLTC USASOCCENT Surge
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Wm. John Gill, PA-C MPASLTC USASOCS
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MG Salvatore F. Cambria, commanding
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The Joint Staff and Combatant Comma
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For the RG-33 MRAP SOF Variant vehi
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USSOCOM Education and Training Upda
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OCONUS LTT requires all the same pr
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Better Training Through Lessons Lea
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also litter Urgent based on the EOD
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ISSUE: MAST pantsRECOMMENDATION: I
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use and amount of carried hemostati
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France, Britain honor U.S. woman wh
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Degree plan for 18D Soldiers announ
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44 Current Events
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46Journal of Special Operations Med
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Necessity of Medical Personnel on t
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Tympanic Membrane Perforation in IE
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overall picture of wounds received,
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than did IEDs. We may conclude that
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dog was included in the unit CASEVA
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DOD. There are approximately 30 per
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Air Force Special Operations Comman
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Page 117 and 118: SEARCH AND RESCUEConfined Space Res
Page 119 and 120: SOCM GLENN MERCERINTRODUCTION“…
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Page 129 and 130: Meet Your JSOM StaffEXECUTIVE EDITO
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