Chronic Spontaneous Urticaria Following mRNA COVID-19 Booster Vaccination at a Military Academy.

Several adverse cutaneous reactions have been reported in the literature after SARS-CoV-2 vaccination with emerging reports on chronic spontaneous urticaria (CSU). However, there is little literature of chronic urticaria after COVID-19 boosters in a military population and the impact on operational readiness. We present a retrospective case series of CSU following Moderna COVID-19 booster vaccinations at the US Naval Academy (USNA). Demographics, clinical features, and impact on readiness were evaluated. Forty-nine students from the USNA were evaluated for urticaria after their third COVID-19 booster vaccination. Seventeen individuals were diagnosed with CSU. The median age was 20 years and predominantly male; the median time interval between vaccination and the onset of urticaria was 11 days. Out of 13 referred to Allergy, 7 patients had CU index performed and 2 were positive. Four patients received a second booster vaccination subsequently and did not have any exacerbation of symptoms. Symptoms were controlled with antihistamines, and none required immunomodulator or immunosuppressive therapies. All students were able to complete their commissioning, and none were referred for a medical board. In this series, USNA students who developed CSU after the mRNA COVID-19 Moderna booster vaccine did not have limitations from commissioning, duty status, or issues with subsequent COVID-19 vaccinations.

Navigating the management complexity in long-term asymptomatic immunodeficiency.

Background: Common variable immunodeficiency disorder (CVID) is a condition associated with recurrent infections and non-infectious outcomes, including lung disease like bronchiectasis and granulomatous and lymphocytic interstitial lung diseases (GLILD), autoimmune disease, enteropathy, and lymphoma. Treatment involves initiation of replacement immunoglobulin (Ig), which is a lifelong commitment. Prior to Ig replacement, life expectancy for patients with CVID was less than 15 years. With replacement Ig, it has improved to over 50 years. In most cases, patients present to a clinician with a history of recurrent infections, and treatment is indicated. However, in patients with asymptomatic disease, the best timing to start treatment can be difficult to determine. Case: We present a case of an otherwise healthy male who had an incidental diagnosis of CVID. Results: Workup revealed hypogammaglobulinemia for over 30 year. Discussion: Though successful in reducing infections, Ig replacement can come with many side effects, as well as a heavy medical burden to the patient and the healthcare system. It is also a big life adjustment, and can greatly affect a patient's quality of life. In the military, a diagnosis of an immunodeficiency, and the need for monthly intravenous immunoglobulin (IVIG) can be detrimental to deployment readiness, and a patient's military career. Risks and benefits need to be weighed prior to initiating Ig therapy.

Cardiac Adverse Events Following COVID-19 Vaccination in Patients With Prior Vaccine-Associated Myocarditis.

Background: Limited information exists to guide shared clinical decision making on COVID-19 vaccination in persons with a prior history of vaccine-associated myocarditis, pericarditis, or myopericarditis (VAMP). The objective of this retrospective observational case series was to characterize cardiac outcomes within 30 days following receipt of 1 or more COVID-19 vaccinations during 2021 in US service members diagnosed with prior non-COVID-19 VAMP between 1998 and 2019. Methods: As part of the collaborative public health mission with the Centers for Disease Control and Prevention for enhanced vaccine adverse events surveillance, the Defense Health Agency Immunization Healthcare Division maintains a clinical database of service members and beneficiaries referred for suspected adverse events following immunizations. Cases in this database recorded between January 1, 2003, and February 28, 2022, were reviewed to identify individuals with prior VAMP who received a COVID-19 vaccine in 2021 and developed signs or symptoms suggestive of VAMP within 30 days following COVID-19 vaccination. Results: Before the COVID-19 pandemic, 431 service members had verified VAMP. Among these 431 patients, 179 had records that confirmed receipt of a COVID-19 vaccine in 2021. Of these 179 patients, 171 (95.5%) were male. Their median age was 39 years (range, 21-67) at the time of COVID-19 vaccination. Most (n = 172; 96.1%) experienced their original VAMP episode after receipt of the live replicating smallpox vaccine. Eleven patients experienced cardiac-suggestive symptoms (chest pain, palpitations, or dyspnea) within 30 days of COVID-19 vaccination. Four patients met the criteria for recurrent VAMP. Three men aged 49, 50, and 55 years developed myocarditis within 3 days of an mRNA COVID-19 vaccine. One 25-year-old man developed pericarditis within 4 days of receiving an mRNA vaccine. All 4 COVID-19 recurrent VAMP cases fully recovered with minimal supportive care within weeks (myocarditis) to months (pericarditis). Conclusions: As demonstrated by this case series, albeit rare, VAMP may reoccur after COVID-19 vaccination among patients who experienced cardiac injury after smallpox vaccination. The clinical characteristics and course of the 4 recurring cases were mild, appearing similar to the post-COVID-19 VAMP described in individuals without a history of VAMP. More research is warranted on factors that may predispose patients to vaccine-associated cardiac injury and which vaccine platforms or schedules may reduce the risk of recurrence among patients who have experienced these events.

Celiac Disease on the Rise in the US Military Population: A 22 Year Retrospective Epidemiologic Study.

INTRODUCTION: We describe celiac disease epidemiology in the US military population. METHODS: This is a population-based study from data collected between 2000 and 2021. Incidence and prevalence rates and descriptive statistics for demographics are presented. RESULTS: Overall, 2248 incident cases of celiac disease were identified. The incidence rate increased from 1.2 to 14.0 per 100,000 person-years and the overall lifetime prevalence increased from 3.1 to 57.4 per 100,000 service members. In gastroenterology clinics, the incidence rate increased from 1.4 to 8.2 per 100,000 person-years, while prevalence increased from 3.3 to 33.4 per 100,000 service members. DISCUSSION: In this study, celiac disease incidence and prevalence increased significantly.

Humanitarian Mission at Home: Walter Reed National Military Medical Center's Experience in Operation Allies Refuge and Operation Allies Welcome.

Military medicine has a long history of humanitarian efforts globally, including responses to natural disasters and as planned medical civil action projects. However, ending two decades of war in Afghanistan, Walter Reed National Military Medical Center (WRNMMC) was tasked to receive up to 63 injured patients with less than 96-hour notice on August 27, 2021. As part of Operation Allies Refuge and transition to Operation Allies Welcome, this article highlights the complicated cross-organizational and multidisciplinary response at WRNMMC where ultimately 277 Afghan patients and nonmedical attendants received medical care and other requirements for resettlement. Lessons learned from coordinating the complex short suspense medical, cultural, and logistic efforts are noted as considerations and practical recommendations for future missions.

Penicillin Allergy Delabeling Can Decrease Antibiotic Resistance, Reduce Costs, and Optimize Patient Outcomes.

BACKGROUND: Antibiotics are one of the most frequently prescribed medications. Among all classes of antibiotics, penicillins are prescribed due to their clinical efficacy, cost-effectiveness, and general safety. Unfortunately, penicillins also are the most common drug allergy listed in patient medical records. Increasing evidence shows that > 90% of patients labeled with a penicillin allergy are not allergic to penicillins and associated ß-lactams. The health care consequences of penicillin allergy in the setting of military medicine and readiness are important to consider. OBSERVATIONS: In the US, 8 to 10% of the population and up to 15% of hospitalized patients have a documented penicillin allergy, limiting the use of these effective antibiotics. When treating a patient with a penicillin allergy, many clinicians avoid prescribing all ß-lactam antibiotics and stay away from cephalosporins due to the concern for potential cross-reactivity. The cost of treating those with a documented penicillin allergy is greater than the cost for those who can receive penicillin, as treatment with broad-spectrum antibiotics often results in longer hospitalizations with increased rates of adverse effects (AEs). Despite preventive programs such as vaccinations, hygiene measures, and prophylactic antibiotics, military personnel are at increased risk for infections due to the military's mobile nature and crowded living situations. CONCLUSIONS: Many patients report an allergy to penicillin, but only a small portion have a true immune-mediated allergy. Given the clinical, public health, and economic costs associated with a penicillin allergy label, evaluation and clearance of penicillin allergies improves clinical outcomes, decreases AEs from higher risk alternative broad-spectrum antibiotics, and prevents the spread of antibiotic resistance. In military personnel, penicillin delabeling improves readiness with optimal antibiotic options and avoidance of unnecessary risks, expediting return to full duty.

Penicillin Allergy Maybe Not? The Military Relevance for Penicillin Testing and De-labeling.

INTRODUCTION: Penicillin allergy is the most common drug allergy reported. About 8-10% of individuals in the USA have a documented penicillin allergy, yet 90% are not truly allergic to penicillin. A penicillin allergy "label" results in increased antibiotic-related adverse reactions and increased health care costs, thus impacting the overall "readiness" of the military. MATERIALS AND METHODS: A review of the current literature and approaches to penicillin allergy and "de-labeling" a patient who reports penicillin allergy was conducted and future strategies to identify and assess military beneficiaries were outlined. Military allergists had a formal discussion at the Tri-service Military Allergy Immunology Assembly regarding the state of penicillin allergy testing in military allergy clinics. RESULTS: A PubMed search yielded 5,775 results for "penicillin allergy" and 484 results for "penicillin allergy testing." There were two formalized penicillin testing programs in the military treatment facilities. In 2017, the military trained nearly 165,000 new recruits. If 5-10% reported a penicillin allergy and 90% were de-labeled, that would yield a $15-30 million cost savings annually. Further, de-labeling of the 9.4 million active duty, beneficiaries and retirees with a 90% success rate could result in even greater savings for the military health care system. CONCLUSION: A penicillin allergy label is a risk to military readiness secondary to associated increases in the length of hospitalizations and emergency department and medical visits. Penicillin de-labeling is a simple intervention that can improve readiness, significantly decrease health care costs and prevent antibiotic resistance, as well as antibiotic-associated adverse events. The military allergist should be "front and center" providing expertise guidance and leadership for clinic and hospital-based penicillin de-labeling efforts which are nested within the antibiotic stewardship programs.

Seasonal Influenza Vaccine Impact on Pandemic H1N1 Vaccine Efficacy.

BACKGROUND: In 2009, a novel influenza A (pH1N1) was identified, resulting in a pandemic with significant morbidity and mortality. A monovalent pH1N1 vaccine was separately produced in addition to the seasonal trivalent influenza vaccine. Formulation of the seasonal influenza vaccine (injectable trivalent inactivated influenza vaccine [TIV] vs. intranasal live, attenuated influenza vaccine [LAIV]) was postulated to have impacted the efficacy of the pH1N1 vaccination. METHODS: We reviewed electronic health and databases, which included vaccination records, and healthcare encounters for influenza-like illness (ILI), influenza, and pneumonia among US military members. We examined rates by vaccination type to identify factors associated with the risk for study outcomes. RESULTS: Compared with those receiving the seasonal influenza vaccine alone, subjects receiving the pH1N1 vaccine, either alone (RR, 0.49) or in addition to the seasonal vaccine (RR, 0.51), had an approximately 50% reduction in ILI, 88% reduction in influenza (RR, 0.11 and 0.12, respectively), and 63% reduction in pneumonia (RR, 0.37 and 0.35, respectively). There was no clinically significant difference in ILI, influenza, or pneumonia attack rates among those receiving the pH1N1 vaccine with or without presence of the seasonal vaccine. Similarly, there was no clinically relevant difference in pH1N1 effectiveness between seasonal TIV and LAIV recipients. CONCLUSIONS: During the 2009-2010 pandemic, the pH1N1 vaccination was effective in reducing rates of ILI, influenza, and pneumonia. Administration of the seasonal vaccine should continue without concern of potential interference with a novel pandemic vaccine, though more studies are needed to determine if this is applicable to other influenza seasons.

New-Onset Asthma and Combat Deployment: Findings From the Millennium Cohort Study.

Recent reports suggest US military service members who deployed in support of the recent conflicts in Iraq and Afghanistan have higher rates of new-onset asthma than those who did not deploy. However, it is unknown whether combat experiences, in addition to deployment, contribute to new-onset asthma risk. This study aimed to longitudinally determine the risk factors for developing asthma, including combat deployment (categorized as deployed with combat experience, deployed without combat experience, or nondeployed), among participants in the Millennium Cohort Study from 2001 to 2013. A total of 75,770 participants completed a baseline survey and at least 1 triennial follow-up survey on deployment experiences, lifestyle characteristics, and health outcomes. Complementary log-log models stratified by sex were used to estimate the relative risk of developing asthma among participants who reported no history of asthma at baseline. In models with adjustments, those who deployed with combat experience were 24%-30% more likely to develop asthma than those who did not deploy. Deployed personnel without combat experience were not at a higher risk for new-onset asthma compared with nondeployers. Further research is needed to identify specific features of combat that are associated with greater asthma risk to inform prevention strategies.

25-hydroxyvitamin D, influenza vaccine response and healthcare encounters among a young adult population.

BACKGROUND: Influenza causes significant morbidity and mortality; the pandemic in 2009-2010 was a reminder of the potential for novel strains and antigenic changes. Studies have shown that vitamin D deficiency may be associated with poor vaccine immunogenicity, therefore we sought to determine if there was a correlation between 25-hydroxyvitamin D [25(OH)D] and influenza vaccine response. METHODS: A retrospective observational study was conducted among young, healthy military members to evaluate the association between total 25(OH)D levels with post influenza vaccination antibody titers and healthcare encounters during the 2009-10 influenza season. Univariate analyses were performed to evaluate whether 25(OH)D levels are associated with baseline characteristics and post-vaccination antibody responses. Multivariable logistic regression models were utilized to determine the associations between antibody responses and 25(OH)D levels adjusting for possible confounders. RESULTS: A total of 437 subjects were studied. Most participants were young adults (91% were 18-39 years of age), 50% were male, and 56% resided in the southern U.S. Overall, 152 (34.8%) were vitamin D deficient, 167 (38.2%) insufficient, and 118 (27.0%) with normal 25(OH)D levels. There were no demographic differences by 25(OH)D category. Only 224 (51.3%) demonstrated a seroprotective anti-influenza post-vaccination titer, which did not vary by categorical 25(OH)D levels [vitamin D deficient vs. normal: OR 1.10 (0.68-1.78) and insufficient vs. normal: OR 1.25 (0.78-2.01)] or continuous vitamin D levels [OR 0.98 (0.84-1.15)]. There were also no associations with increased influenza like illnesses, respiratory diagnoses and healthcare encounters between the vitamin D groups. CONCLUSION: Vitamin D insufficiency and deficiency were highly prevalent despite evaluating a young, healthy adult population. There were no significant associations between 25(OH)D levels and post-vaccination antibody titers to influenza vaccine. Further studies are required to discover strategies to improve vaccine efficacy as well as to determine the role of 25(OH)D in vaccine immunity.

A population-based epidemiologic study of adult-onset narcolepsy incidence and associated risk factors, 2004-2013.

An increase in narcolepsy incidence was noted after the novel pandemic influenza of 2009, leading to further interest in risk factors associated with this disease. However, there is limited data on the epidemiology of narcolepsy, particularly in the adult population. Therefore, we sought to examine narcolepsy incidence rates in the United States and describe associated characteristics. We performed a population based epidemiologic study of active duty military personnel. All outpatient clinics in the continental United States providing care for active duty military between 2004 through 2013 were included utilizing existing databases. Narcolepsy was defined in 3 ways: (1) 2 diagnoses of narcolepsy within 6months of each other, one made by a sleep expert; (2) 2 diagnoses by any provider followed by a narcolepsy prescription within 14days of last visit; and (3) procedure code for a sleep study followed by a narcolepsy diagnosis by a sleep expert within 6months. There were 1675 narcolepsy cases. Overall incidence of narcolepsy trended from 14.6 to 27.3 cases per 100,000 person-years, with an increase starting after 2005-2006 and peaking during the 2011-2012 influenza season. Higher frequencies were seen among females, non-Hispanic blacks, and members living in the south. Narcolepsy incidence rates among active duty military members are higher than previously described. The reason for the steady rise of incidence from 2005 to 2006 through 2011-2012 is unknown; however, these findings require further exploration. We detected risk factors associated with the development of narcolepsy which may aid in future study efforts.

Combat internist: the internal medicine experience in a combat hospital in Afghanistan.

Military internists and internal medicine subspecialists are physicians who generally work in traditional internal medicine settings. However, when deployed to combat settings, they must prepare and adapt their skills for a wide spectrum of complex, polytrauma, and multinational patients. There are limitations in personnel, equipment, and technical resources that make the circumstances complex and demanding. This article highlights some of the unique roles, challenges, and experiences of four military internists at the NATO Role 3, a deployed combat hospital in Afghanistan.

Idiopathic CD4 lymphocytopenia manifesting as refractory genital dysplasia.

BACKGROUND: Idiopathic CD4 lymphocytopenia is an immunodeficiency disorder with low absolute CD4 T-lymphocyte count with no evidence of human immunodeficiency virus or other known cause. CASE: A 22-year-old woman presented with a high-grade Pap test result. Work-up demonstrated cervical intraepithelial neoplasia 3 and vaginal intraepithelial neoplasia 3 with extensive condyloma. She presented 6 months after her initial treatment with recurrent disease and was referred to the immunology department, where she was found to have profound lymphopenia. After further evaluation, idiopathic CD4 lymphocytopenia was diagnosed. CONCLUSION: Idiopathic CD4 lymphocytopenia is a rare acquired immunodeficiency. Although genital dysplasia is common in young women, this case demonstrates the importance of determining other etiologies of recurrent human papillomavirus infections and possible immunodeficiencies that may affect management and outcomes.