Terry Walters MD MPHOffice of Public Health

A 30 year old Veteran seeks care from his primary care provider for headache, chills, myalgias, fevers, and a non-productive cough. The Veteran is concerned about burn pits.

What are critical questions you should ask? Have you been deployed? Yes I was in Iraq What was your job in the military? I was a 68T Don’t stop there! Ask if you don’t know

what a 68T does. (It is an Army Veterinarian Technician)

High index of suspicion of uncommon infectious diseases in new VeteransHealth care providers caring for Veterans need to ask a travel & job history and be aware that OIF/OEF Veterans have been exposed to a variety of infectious diseases with long term adverse health effects.This lecture will cover 9 infectious diseases that have been found to be presumptively associated with service in OIF/OEF. These Veterans may be eligible for service connection.

1. Malaria2. Brucellosis3. Campylobacter Jejuni4. Coxiella Burnetii (Q fever)5. Mycobacterium Tuberculosis6. Nontyphoid Salmonella7. Shigella8. Visceral Leishmaniasis9. West Nile Fever

The VA determines existence of chronic disabilities incurred or

aggravated by military service. VA compensates the veteran for

the residuals of such disabilities.

Three requirements for a grant of service connection

◦ An in-service event (incurred or aggravated)

◦ A current condition, and

◦ A medical nexus establishing a link

Generally, there must be evidence showing a disability resulted from injury or disease in service

Presumptions of service connection relieve Veterans of burden of providing evidence relating to either the existence of an event in service or the nexus between an event in service and the current disability

“It must be at least 10% disabling within 1 year from date of military separation.”

◦ Malaria, Brucellosis, Campylobacter Jejuni, Q fever, Nontyphoid Salmonella, Shigella

No time constraint – Tuberculosis, Visceral Leishmaniasis

Institute of Medicine (IOM) considered diseases with the following characteristics

1.Are prevalent in Southwest Asia (SWA)2.Have been diagnosed among U.S. troops serving in SWA3.Are known to cause long-term adverse health effects

Classic symptoms of malaria: cyclical occurrence of sudden coldness followed by rigor and then fever and sweating lasting four to six hours, occurring every two days in P. vivax and P. ovale infections, while every three days for P. malariae.

Other sx: shivering, arthralgia (joint pain), vomiting, anemia (caused by hemolysis), hemoglobinuria, retinal damage, and convulsions

Diagnosis: Blood film (preferred), Antigen tests, PMR Treatment: WHO guidelines 2010, artemisinin-based

combination therapies (ACTs) recommended for uncomplicated P. Falciparum malaria. P. vivax requires clearance of liver forms with primaquine

Issues: neuropsychiatric side effects can occur with Mefloquine (Larium) more information available at http://www.warrelatedillness.va.gov/education/exposures/lariam.asp

Highly contagious zoonosis caused by ingestion of unsterilized milk or meat from infected animals or close contact with their secretions. ◦ Ask about consumption of local food (unpasteurized dairy

products) or handling of animals in SWA Sx. include undulant fever, sweats, headaches, back pains,

and physical weakness. Severe infections of the central nervous systems or lining of the heart may occur.

Can also cause long-lasting or chronic symptoms that include recurrent fevers, joint pain, and fatigue

Diagnosis: agent in blood or bone marrow (very slow growing) also antibodies

Treatment: difficult – combination of doxycycline (45 days) and streptomycin (14 days)

curved, helical shaped, non-spore forming, Gram-negative, bacteria commonly found in animal feces

Most common causes of human gastroenteritis in the world

linked with subsequent development of Guillain-Barré syndrome (GBS)

Infection with C. jejuni usually results in enteritis, which is characterized by abdominal pain, diarrhea, fever, and malaise.

The use of antibiotics, on the other hand, is controversial except in severe cases

Severe (accompanying fevers, blood in stools) or prolonged cases may require ciprofloxacin, erythromycin, azithromycin or norfloxacin

Small obligate intracellular bacterial Gram-negative bacteria that are highly resistant to environmental stresses

Inhalation of one organism will yield disease in 50% of the population making C. burnetii the one of the most infectious organism known to man.

Infection results from inhalation of endospores, and from contact with the milk, urine, feces, vaginal mucus, or semen of infected animals. Rarely, the disease is tick borne. The incubation period is 9–40 days.

Disease occurs in two stages: an acute stage that presents with headaches, chills, and respiratory symptoms, and an insidious chronic stage.

Diagnosis is usually based on serology While most infections clear up spontaneously, treatment

with tetracycline or doxycycline appears to reduce the symptomatic duration and reduce the likelihood of chronic infection. (which can take up to 4 years of antibiotics)

Low infectivity ~10% of people infected with M. tuberculosis ever develop the disease

Bacillus may lie dormant in the body for decades until reactivation

Non-specific initial symptoms, loss of appetite, fever, productive cough, loss of energy, weight loss, and night sweats

Diagnosis: The presence of acid-fast-bacilli (AFB) on a sputum smear, Interferon-Gamma Release Assays (IGRAs)

Treatment complex due to multi drug resistance

Endotoxin from Salmonella cause most sx. Incorrectly prepared meats, infected eggs, egg

products, and milk when not prepared, handled, or refrigerated properly. Handling reptiles or rodents, tainted fruits or vegetables.

Sx: Fever, Chills, Headache (with a sudden onset), Stomach cramps, Diarrhea, Nausea, Vomiting◦ Sx can last up to 8 weeks usually 4-7 days

Complications: Abscesses, Reiter’s Syndrome leading to reactive arthritis, colitis

Treatment: prevention of dehydration, surveillance for complications

Shigellosis is an food-borne infectious disease caused by a group of bacteria called Shigella.

Most who are infected with Shigella develop diarrhea, fever, and stomach cramps starting a day or two after they are exposed to the bacteria. The diarrhea is often bloody.

Shigellosis usually resolves in 5 to 7 days. Usual treatment is supportive with fluid

replacement Reiter's disease and hemolytic uremic syndrome

are possible sequelae that have been reported in the aftermath of shigellosis.

Parasitic disease spread through the bite of a sand fly

Second-largest parasitic killer in the world (after malaria), responsible for an estimated 500,000 cases each year worldwide

Sx: include fever, weight loss, mucosal ulcers, fatigue, anemia and substantial swelling of the liver and spleen.

without proper treatment the mortality rate for VL is close to 100%

Diagnosis: diagnosis is visualization of the parasites in splenic or bone marrow aspirates. Serologic testing also available

Treatment: Paromomycin IM Injection, Amphotericin B, oral Miltefosine

Mosquito borne viral (flavivirus) disease Infection can follow three paths, asymptomatic

(78%), mild febrile illness (21%), encephalitis (1%)

Diagnosis: Serology of blood or CSF Risk factors for developing a more severe form

of West Nile virus include:◦ Conditions that weaken the immune system, such as

HIV, organ transplants, and recent chemotherapy◦ Older or very young age◦ Pregnancy

Treatment: some HIV antiretroviral drug have shown some promise

Complications from severe West Nile virus infection include:◦ Brain damage (10% of those with encephalitis)◦ Permanent muscle weak

Our Veteran recently returned from Iraq with non-specific symptoms could who a variety of significant infectious diseases associated with his service.

Many of these infectious diseases are uncommon in the US and have significant sequelae if untreated.

Questions?