Eumycetoma: A Perspective for Military Primary Care.

This is a case report of a 42-year-old woman who presented to a clinic with a history of progressive left foot and ankle swelling. She had a suspected history of myectoma, but had never been officially diagnosed despite repeated cultures and debridements over the course of decades. The inciting event occurred approximately 30 years prior in her home country of Belize. Her wound culture revealed Scedosporium apiospermum as the causative agent. Treatment included surgical debridement and oral antifungal therapy. This case represents an interesting adjunct to the differential diagnosis for military physicians, as mycetomas are prevalent in many of the areas where our forces are deployed and may only present after the service member has left active service because of its naturally indolent course.

Travel-Related Risk Behaviors and Antibiotic Use Among Older Travelers.

BACKGROUND: Antibiotic stewardship in the pretravel care of older adults is important to effectively treat infections while minimizing harm from side effects and unnecessary antibiotic use. The objective of this study was to compare the characteristics, risk behaviors, infectious diseases, and antibiotic use between older (≥60 years) and younger (18-59 years) travelers. METHODS: TravMil is a prospective, observational cohort of United States (US) Department of Defense beneficiaries traveling outside the continental US for ≤6.5 months. For this analysis, we included adults enrolled pretravel between January 2010 and August 2018 and excluded active duty personnel on deployment. Pre and post-travel surveys captured trip characteristics, exposures, illnesses, and antibiotic use. RESULTS: A total of 1742 travelers were analyzed: 747 (42.9%) were aged ≥60 years and 995 (57.1%) were aged 18-59 years. Older travelers were less likely to engage in high-risk dietary behaviors and experience travelers' diarrhea than younger travelers (18.2% vs 22.9%; P < .05). Influenza-like illness (12.5%) and febrile illness (3.4%) occurred less frequently in the older cohort. Antibiotic use for self-treatment was common in both age groups (25.7% vs 26.7%) and often inappropriate, for example, for treatment of occasional loose stool or mild travelers' diarrhea (67.0% [67/100] in older adults vs 57.6% [83/144] in younger adults; P < .05), and influenza-like illness (63.4% [64/101] vs 58.6% [68/116], respectively; P < .05). CONCLUSIONS: Older travelers were less likely to engage in high-risk behaviors and experience travelers' diarrhea, and both age groups experienced mild, self-limited infections. Inappropriate use of antibiotics was common, suggesting that antimicrobial stewardship should be emphasized at pretravel counseling with international travelers.

Emphysematous Gastritis in a Patient with Untreated Cyclic Vomiting Syndrome.

Emphysematous gastritis (EG) is an uncommon and potentially fatal disease characterized by gastric pneumatosis in the setting of infection. While this disease has been described in the literature, it has not previously been identified as a potential complication of cyclic vomiting syndrome. We describe a patient with a history of cyclic vomiting syndrome who presented acutely ill and was found to have radiographic, endoscopic, and histologic evidence of EG. This case illustrates how an untreated functional bowel disorder can lead to severe and potentially fatal complications.

Extraintestinal Manifestations Are Common in Obese Patients with Crohn's Disease.

INTRODUCTION: Crohn's disease (CD) is a chronic condition associated with the risk of malabsorption. The incidence of obesity worldwide is increasing, and the effect of obesity on patients with CD is unknown. We aim to identify traits related to obesity in a cohort of patients with CD. METHODS: We conducted a retrospective study of 209 adult patients with CD. Age, Montreal disease classification, sex, race, duration of disease, erythrocyte sedimentation rate, C-reactive protein levels, physician global assessment, endoscopic appearance, histologic activity, medication use, and body mass index (BMI) were collected about each patient. RESULTS: The mean age was 43.4 ± 14.9 years; 68.9% were white, and 51.7% were male. The mean duration of disease was 11.0 ± 10.6 years. The mean BMI was 26.8 ± 5.7: underweight 7.7%; normal weight 29.3%; overweight 38.0%; and obese 25%. Patients with higher BMI were more likely to have extraintestinal manifestations (EIM) (P = 0.005) and more likely to have nonarthralgia extraintestinal manifestations (P = 0.047). There was a linear association between proximal CD and decreasing BMI (underweight 31.3%, normal weight 14.8%, overweight 15.0%, obese 7.7%; P = 0.046). There was no difference in BMI between patients with and without perianal disease (P = 0.216). CONCLUSIONS: Most patients were overweight or obese, which correlates with national population trends. Our data suggest disease location plays a role in weight modulation in patients with CD. Increased extraintestinal manifestations in patients with high BMI suggests that the chronic inflammation associated with obesity may play a role in extraintestinal inflammation.

Tickborne diseases other than Lyme in the United States.

Tickborne diseases are increasing in the United States, and the geographic range of tick vectors is expanding. Tickborne diseases are challenging to diagnose, as they present with vague symptoms such as fever, constitutional symptoms, and nonspecific laboratory abnormalities. A high degree of clinical suspicion is required to make a diagnosis, as patients often do not recall a tick bite. The availability of laboratory testing for tickborne diseases is limited, especially in the acute setting. Therefore, if a tickborne disease is suspected, empiric therapy should often be initiated before laboratory confirmation of the disease is available. This article summarizes the most common non-Lyme tickborne diseases in the United States.

Idiopathic renal infarction in a previously healthy active duty soldier.

Renal infarction (RI) is rare, and usually occurs in patients with associated comorbidities. The majority of reported cases have presented with laboratory abnormalities, most notably leukocytosis and elevated lactate dehydrogenase (LDH). A 50-year-old active duty white male nonsmoker without medical history presented with flank pain. Urinalysis, complete blood count, LDH, and serum creatinine were normal. Contrast-enhanced computed tomography of the abdomen and pelvis showed a right-sided RI. The patient was admitted to the hospital and anticoagulated. Laboratory values remained normal, and a comprehensive workup failed to reveal an etiology for his RI. RI is rare, and affected patients often present with symptoms similar to more common conditions such as lumbago or nephrolithiasis. Elevated LDH may be a clue to the diagnosis, but unlike 92% of the reviewed cases, our patient presented with a normal value. This case suggests that clinicians should consider RI in patients with persistent symptoms for whom more common causes of flank pain have been excluded; including in nonsmoking patients without apparent risk factors for infarction who present with a normal LDH and no leukocytosis.