Tuberous sclerosis in a military pilot.

Tuberous sclerosis (TS) is a multisystem disorder characterized by hamartomas in various organs. It usually manifests itself during infancy or childhood with neurological features, including mental retardation and seizures. We present the case of a military pilot who was diagnosed with TS at 22 yr. of age after he had completed flight training. Suspicion of TS arose from evaluation of a chronic rash around the pilot's nose, and diagnosis was confirmed based on the presence of multiple calcified nodules on CT imaging of the brain. No neurological abnormalities were found. The primary aeromedical concerns were the risk of seizures or development of tumors at sites that might lead to sudden incapacitation. Hamartomas can be reliably detected at an early stage by means of annual history, physical examination, and imaging of tumor-prone organs. After review of the literature and consultation with medical specialists, we assessed the risk of adult-onset seizures in a TS patient without preexisting neurological findings as scarce. The pilot was therefore granted a waiver limited to flying a two-pilot helicopter with a program of tight medical follow-up.

Evaluation of systemic allergy in a jet aviator.

Cholinergic urticaria and exercise-induced anaphylaxis (EIA) are related conditions. Cholinergic urticaria is caused by a rise in body core temperature and usually results in pruritus, skin lesions and, rarely, in serious respiratory and cardiovascular compromise. EIA can result in a cardiovascular compromise and syncope. Ingestion of certain foods may be associated with EIA. A 41-year-old jet pilot complained of 3-month onset of pruritus and urticaria during treadmill exercise. On one occasion, after a routine exercise bout, albeit with pruritus and urticaria, he experienced two short episodes of syncope. Treatment with a nonsedating H1-receptor antagonist was started. He underwent a unique challenge test that we designed. This included passive warming as well as exercising in a hot (temperature of 40 degrees C at 40% humidity) environment. After passing this test uneventfully, the pilot was returned to jet flight with a copilot and, subsequently, to full active duty.

Head-up tilt test for recurrent syncope in pilots.

Syncope is defined as a sudden temporary loss of consciousness and postural tone that is associated with spontaneous recovery. Vasovagal or neurocardiogenic syncope is a common and usually benign cause of syncope. The mechanism may be cardioinhibitory, vasodepressor, or both. Diagnosis is usually made by a typical patient history with a definite trigger. Although vasovagal syncope is considered a benign condition, its occurrence in an aviator is worrisome, especially if recurrent and without a definite trigger. The head-up tilt test (HUTT) is used as a vasovagal syncope challenge test. A drop in BP and asystole during HUTT suggest a tendency to recurrent vasovagal syncope. We describe two military aviators with recurrent episodes of vasovagal syncope, one with definite triggers and one without. Both had positive HUTTs. The aviator with trigger-defined vasovagal syncope was disqualified from high-performance platforms due to his positive HUTT. The second case was disqualified from all platforms, irrespective of his HUTT result, because a definite trigger was not definable for all his syncopal episodes.

Diabetes mellitus type 1 in five military aviators: flying with insulin.

OVERVIEW: Diagnosis of diabetes mellitus (DM) type 1 results in medical disqualification for all military aviation duties all over the world. The main concern is hypoglycemia, which can cause sudden incapacitation. Efforts to reduce the glucose levels and long-term complications increase the frequency of hypoglycemia. PURPOSE: This paper reviews five newly diagnosed cases of DM type 1 in Israeli Air Force aviators that presented over the last 15 yr. Four of the aviators were allowed to continue on active duty with limitations and one was disqualified. METHODS: The records of all five diabetic aircrew were reviewed. Aircrews are tested every 3 mo for HbA1c levels. Every year they receive dilated fundoscopic eye examination. They have lipid levels drawn annually and are seen by both an endocrinologist and a flight surgeon for general medical examinations. RESULTS: Four of the aviators continued on active duty for years. No symptomatic hypoglycemia or sudden incapacitation occurred. Three of the four airmen experienced undesirable HbA1c levels. CONCLUSIONS: Our experience indicates that safely flying with newly diagnosed DM type 1 is possible. The cost of the demanding lifestyle of military aircrew members and the fear of hypoglycemic episodes can result in periods of sub-optimal glucose control.

Sinus vein thrombosis following exposure to simulated high altitude.

A relation exists between high altitude exposure and a hypercoagulable state, the nature of which is not entirely clear. This has been mostly reported in mountain climbers. We report a 19-yr-old female, working as a high-altitude chamber instructor, who presented with severe frontal headaches which persisted for a month following routine high altitude chamber training. The patient was in generally good health and was using oral contraceptives for 3 yr prior to the event. Due to the unremitting nature of the symptoms, the patient was admitted to a neurology department, and computerized tomography (CT) and magnetic resonance imaging (MRI) were performed. Sagittal and transverse sinus vein thrombosis were diagnosed and anticoagulant therapy was initiated (low molecular weight heparin followed by warfarin). Following treatment, a slow symptomatic improvement was observed, and the patient was discharged. On discharge, it was recommended she continue oral anticoagulant therapy (warfarin). A complete coagulation screening panel was performed, which was negative. Although the relation between high altitude exposure and a hypercoagulable state is well known, this is the first time a case of sinus vein thrombosis has been reported after high altitude chamber training. Careful history and closely monitored medical follow-up should be performed on all designated staff exposed to simulated altitude. Even though there is no conclusive evidence regarding it, we suggest, as a matter of caution, that women using oral contraceptives should consider their risks before deciding to undertake exposure to simulated altitude in chambers. Literature review and detailed recommendations for prevention are provided.