festering sores will be returning home with Operation Iraqi Freedom's warfighters

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Source:: U.S. Army Homepage 4 Mar 2004 [edited]

<http://www4.army.mil/ocpa/read.php?story_id_key=5726>

 

 

Army treating hundreds of leishmaniasis cases

--

A little-known parasite that causes chronic, festering sores will be

returning home with some of Operation Iraqi Freedom's warfighters.

Cutaneous leishmaniasis, which affects the skin, is caused by a sand fly

bite that deposits the parasite that eventually causes weeping sores that

don't heal as quickly as regular sores.

 

" The majority of these are lesions on the face or on the hands over joints.

So in the short term, it's just not pleasant to have a lesion that won't

heal potentially for up to a year -- and some of these get quite large, "

said Lt. Col. Peter Weina, a " leishmaniasis " expert at the Walter Reed Army

Institute of Research. " In the long term, the problem is the scarring,

which can be disfiguring if it's on the face and can limit movement of the

hands if it's over a joint. "

 

Iraq's sand flies are most active during warm nights from March to October,

so troops on the move during Operation Iraqi Freedom were right in the

middle of " Sand fly Central. "

 

" In the march up to Baghdad, people would literally fall asleep on their

HUMV or out in the middle of the desert, so we had enormous amounts of

exposure in the evenings in areas where there were a lot of sand flies, "

said Col. Alan Magill, another of Walter Reed Army Institute of Research's

experts on leishmaniasis. Leishmaniasis experts suspected the disease was

going to be a problem for troops, but until Weina arrived in theater to

serve with the 520th Theater Army Medical Laboratory, they didn't know just

how big the problem was. Initially sent to look for weapons of mass

destruction, Weina's team also looked for common diseases in the area, like

leishmaniasis, to see what risk they posed.

 

By April 2003, fears were confirmed. " We found sand flies in the area and

started testing them and found some extraordinary infection rates in the

flies, " he said. " We expected to find maybe 1/10 of one percent of the sand

flies to be infected with leishmaniasis, and we were finding 2 percent of

the sand flies were infected in some locations. "

 

Finding that many infected sand flies meant a huge increase in the

potential number of cases, so Weina and his team went into full prevention

mode. " We went to units and talked to everyone from the commander on down

to the private. They needed to know that the best thing to do with this

disease was to prevent getting it in the first place, " he said.

 

" We did everything from stand-up comic routines out in an opening in the

middle of tents, all the way to full briefings in conference rooms. " Though

travel was hazardous, Weina's message to the audiences he reached was

simple: Wear DEET insect repellent so sand flies don't bite; use

permethrin, a pesticide, on uniforms to keep sand flies away; and sleep

under mosquito nets that have been treated with permethrin.

 

The discovery of the leishmaniasis problem coincided with the war, so

getting the word out on the disease wasn't easy, Weina said. " The problem

is that some (lesions) look like any other type of sore that you may have

with a bacterial infection, but they just don't get better, " Weina said.

" We treated with antibiotics first. Then if the antibiotics failed, we

considered leishmaniasis. "

 

So far, more than 500 cases of leishmaniasis have been diagnosed. Magill

said he hedges when he's asked how many total cases to expect. " The simple

answer is: I don't know. But if you extrapolate, you're probably looking at

the 750

to 1250 range. It could be higher. "

 

Because the disease is difficult to diagnose without a lab and experts

equipped to look for it, all leishmaniasis smears are currently sent to the

Walter Reed Army Institute of Research for confirmation. The institute, in

fact, has the only leishmaniasis lab in the country that is accredited by

the College of American Pathologists and is operated in accordance with the

Clinical Laboratory Improvement Act.

 

The ability to deliver a diagnosis lets the lab cross the boundary that

typically exists between research and health care, Magill said. " Though the

(institute's leishmaniasis) research program was eliminated (in 1996), the

lab was maintained for just the scenario being played out today, " he said.

 

Many of the leishmaniasis researchers, like Weina and Magill, are also

caregivers at the only U.S. military hospital where the treatment for

leishmaniasis can be offered, the Walter Reed Army Medical Center. Because

the drug of choice used to treat the most severe cases was never submitted

to the Food and Drug Administration for its approval, the drug must be

offered as an investigational new drug, which means following strict

research protocols and keeping meticulous records when the drug is given.

The drug, sodium stibogluconate (Pentostam), is hardly " new, " as it's been

used for over 50 years to successfully treat leishmaniasis.

 

Treatment typically consists of an outpatient regimen of receiving the drug

intravenously daily for 20 days, though the type of leishmaniasis acquired

in Iraq, leishmaniasis major, responds in 10 days. The volume of patients

who need treatment has challenged both the institute and the Walter Reed

hospital, Weina said. " This is really the largest outbreak in the history

of the military since World War II. I know for a fact that Colonel

(Naomi) Aronson (the doctor who kept the hospital's IND current) has

brought her sleeping bag to her office so she can sleep there if she needs

to, " he said. " We've never been set up to be able to treat this many cases. "

 

To put the current leishmaniasis outbreak into perspective, Magill said

that for Operations Desert Shield and Storm, the official number of

leishmaniasis cases was 32. " When you're treating 30 to 40 cases a year at

the most, it's no big deal having the patients come to Walter Reed Army

Medical Center to be treated, " Weina said. " But having 400 in a couple of

months, now there's a problem. "

 

Weina and Magill are traveling to posts with large numbers of returning

troops, like Fort Campbell, Ky.; Fort Hood, Texas; and Fort Carson, Colo.,

to let the troops and the medical professionals there know what to look

for. " The only problem is, like with most of tropical medicine, the

expertise to make the diagnosis is not well distributed. To physicians and

lab technicians at Fort Campbell, this is not something many of them have

seen in their entire careers, " Magill said.

 

The [leishmaniasis] experts are also looking at other treatment options for

patients, including freezing the lesions or using a device that uses heat

to kill the parasite. " There's a good biologic rationale for it heat

therapy) to work and some data that we've seen that says it works, but we

are reluctant to recommend a treatment when there's been no experience. "

 

15 patients at Walter Reed are currently enrolled in a study see whether

the thermal device works, and results should be available by March 2004. At

the hospital, Magill has seen patients who have more than 30 lesions,

patients with lesions up to 3 inches in diameter and patients with nodular

lesions that look like tumors. The good news, he said, is the lesions do

heal, even without any treatment.

 

The bad news is healing can take up to a year without effective treatment.

" In the natural history of these lesions, if you do nothing, even for the

worst lesions, they will get better, he said. " But cosmetically this is

very damaging. If you're walking around with some of these big lesions on

your face, psychologically there's a big impact there. This is an

operationally acquired disease, and it's our job to address that. "

 

[byline: Karen Fleming-Michael, Staff writer, Fort Detrick, MD Standard

newspaper]

 

 

 

 

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