A Case of Multidrug-Resistant Tuberculosis in an Active Duty Military Health Care Worker.

Cases of active tuberculosis (TB) in the U.S. Military have fallen over the last century in large part due to improved screening and treatment options. The subset of multidrug-resistant TB (MDR-TB) is almost nonexistent within the U.S. Military. We present a case of MDR-TB in an active duty U.S. Military health care worker and discuss several considerations for treatment that may present challenges for U.S. Military medical practitioners. A 30-year-old active duty Soldier was referred to Army public health services after a bronchoscopy sample was positive for Mycobacterium tuberculosis complex. Sputum smears were negative for acid-fast bacilli, suggesting lower risk for community spread. One month after initiation of the standard 4-drug regimen for active TB, genetic susceptibility testing found the patient's M. tuberculosis isolate to be resistant to rifampin, isoniazid, and pyrazinamide. Contact investigation efforts among co-workers and family members fortunately found no new interferon-gamma release assay conversions. Coordination of public health assets to ensure a successful treatment regimen occurred across varied local, state, and federal agencies. Atypical medications required coordination with the FDA for procurement. An extensive surveillance plan for medication adverse effects was required. Finally, questions of public health authority versus patient autonomy arose requiring multidisciplinary input and ethical discussions.

Forage and You Shall Find: Cardiac Glycoside Poisoning and the Danger of Foraging.

Amateur foraging, which can be described as the gathering of uncultivated plants for sustenance or recreation, supports many benefits for the forager and the environment; however, it can also present the hazard of unintentional poisoning. Asclepias syriaca, or common milkweed, is a potentially edible plant that also contains cardioactive steroids akin to digoxin. A 38-year-old female amateur forager boiled and sautéed 8-10 milkweed pods before ingesting them. She developed vomiting and heart palpitations within 1 hour and presented to an emergency department 3 hours after ingestion. Her exam was within normal limits with exception of heart rate in the 40-50s without hypotension. ECG was notable for sinus bradycardia. Laboratory analysis was notable for a detectable serum digoxin concentration. Life-threatening toxicity did not occur. Recently, some military services have advocated for foraging as a means to sustain far-forward troops. However, misidentification of plants by inexperienced foragers can result in severe toxicity or death. If mass foraging becomes part of expeditionary operations, military clinicians must be trained and prepared for the potentially severe plant-related poisonings.