Special Operations Forces Medical Handbook

5-56

PPD skin testing is done as follows:

1. Placement of PPD: inject 5 IU (0.1 mL) intradermally into flexor surface of LEFT forearm (so you will
   remember where to look for reaction).


2. Interpretation of PPD reaction:
   a. Measure diameter (in mm) of INDURATION or swelling (not redness) of reaction, when viewed in
   cross-section at 48-72 hours.
   b. >5mm is positive in HIV patients, and in close or household contacts of a patient with an active TB
   infection.
   c. >10mm is positive for those personnel exposed to people at high-risk for having TB. This standard applies
   to medical personnel and team members.
   d. >15mm is positive for personnel with no risk factors for exposure. This standard applies to most
   Americans.

Zoonotic Disease Considerations
Agent: Mycobacterium bovis
Principal Animal Hosts: Cattle
Clinical Disease in Animals: Progressive emaciation, lethargy, weakness, anorexia, low-grade fever;
chronic bronchopneumonia with moist cough, progressing to tachypnea and dyspnea.
Probable Mode of Transmission: Ingestion, inhalation (occupational exposure to farmers)
Known Distribution: Worldwide; rare in N. America, western Europe, Japan, Australia, New Zealand

ID: Nontuberculous Mycobacterial Infections (NTM)

LTC Duane Hospenthal, MC, USA

Introduction: Nontuberculous mycobacterial (NTM) or mycobacteria other than tuberculosis (MOTT)
infectious diseases include lymphadenitis caused by Mycobacterium avium complex (MAC) and M.
scrofulaceum; skin and soft tissue infection secondary to M. fortuitum, M. abscessus, M. marinum, and M.
ulcerans; and pulmonary disease, most commonly secondary to MAC or M. kansasii. Lymphadenitis in
children age 1-5 years is most commonly caused by M. avium complex. In adults, lymphadenitis is due to
M. tuberculosis in 90% of cases. Pulmonary syndromes are usually chronic, often occurring in persons with
other underlying pulmonary disease.

Subjective: Symptoms
Lymphadenitis (painless enlargement of the lymph nodes of the neck), usually unilaterally; skin and soft tissue
infections - edema, erythema; pulmonary infection - chronic, productive cough with fever and weight loss;
accompanied by malaise, night sweats and hemoptysis.
Focused History: Do you have any swollen areas? (lymphadenitis usually involves only one lymph node
chain) Have you been in contact with any kittens? (Cat scratch disease/bartonellosis is spread by young
cats; causes lymphadenitis)

Objective: Signs
Using Basic Tools:
Lymphadenitis: Enlarged, unilateral nodes of the neck (usually anterior cervical chain) that may
spontaneously form sinus tracts and drain. No overlying erythema. Individual nodes are difficult to identify.
Normal vitals.
“Swimming pool or fish tank granuloma” caused by M. marinum starts as a papule (usually on extremity) that
slowly enlarges and ulcerates. These lesions are associated with water or fish exposure. Introduction of the
organism is likely via an abrasion or puncture.
Pulmonary disease: Presents similar to tuberculosis (see ID: TB). Perform PPD testing to rule out
tuberculosis.
Using Advanced Tools: CXR may reveal thin-walled cavities and more pleural thickening than tuberculosis.