Chapter Four

BACTERIAL DISEASES (OTHER THAN MYCOPLASMA)

TYPHOID FEVER
Introduction
Typhoid fever is a life-threatening illness caused by the bacterium Salmonella
typhi. The infection is common through the world except in the United States,
Canada, Australia, Japan, and Western Europe. There are about 400 cases per
year in the United States. S. typhi colonizes only humans, so spread of the dis-
ease requires close contact with an infected individual, either somebody with
an active infection or a chronic carrier. The infection is transmitted via the
fecal-oral route, and the most common method by which infection is acquired
is through consumption of contaminated food and water. Infected individuals
have the bacteria in the blood and digestive tract. A small percentage of indi-
viduals recover from the acute infection but become carriers and continue to
shed the bacteria and therefore remain infectious. The classical case is that of
“Typhoid Mary” Mallon who infected many individuals for whom she prepared
food as a professional cook.

What Infected Patients Experience

The incubation period for typhoid fever depends on the amount of organism
ingested and the immune status of the patient, with a range from a few days to
one or two months. Then the patient experiences the insidious onset of a sus-
tained fever with temperatures up to 103oF–104oF accompanied by headache,
malaise, anorexia, relative bradycardia (out of proportion to what would be
expected with high fever), chills, constipation or diarrhea, and a nonproductive
cough (Keusch, 1991; Centers for Disease Control and Prevention, 1990). With
rapid treatment, patients usually feel better within a few days.

The spectrum of illness ranges from a brief illness to an acute severe infection
with central nervous system involvement and circulatory collapse. With severe

31
32 Infectious Diseases

infections, patient may have altered mental status, hepatitis, meningitis

(Abuekteish et al., 1996), myocarditis (du Plessis et al., 1997; Hewage et al.,
1994), pneumonia, arthritis (Fule and Chidgupkar, 1994), chorioamnionitis
(Hedriana et al., 1995), and hemorrhage or perforation (Keusch, 1991). Un-
treated, up to 20 percent of patients may die from the above or other complica-
tions.1 About 3–5 percent of patients become long-term carriers if they remain
untreated. Many of these individuals never realize they were infected.

Diagnosis

A probable diagnosis can be made when a patient has a clinically compatible

illness associated with a confirmed outbreak. Confirmed diagnoses require
isolation of S. typhi from blood, stool, or another clinical specimen (Centers for
Disease Control and Prevention, 1990).

Prevention

The main preventative measures for typhoid fever include avoiding potentially
infectious foods and drinks and vaccination against infection. Individuals who
travel to areas where typhoid is common should be vaccinated. Both oral and
injectable vaccines are available (Hone et al., 1994; Klugman et al., 1996; Kollar-
itsch et al., 1997; Levine et al., 1996). Even those vaccinated against typhoid
fever should be careful about what they eat, since the vaccine is not 100 percent
effective.

Correlation with Gulf War Illnesses

Serologic markers exist to identify patients infected, either at present or in the

past, with S. typhi. Investigation of Gulf War veterans has not detected in-
creased antibody levels to this organism. Furthermore, in most patients this
disease is either self-limited or results in severe symptoms that would precipi-
tate immediate treatment.

Summary

Typhoid fever is caused by the bacteria S. typhi. This bacteria is found in most
parts of the world, although it is not common in the United States, except in
individuals returning from international destinations where infection is more
common. Because this disease is easily diagnosed and generally lasts only a

______________
1CDC website: http://www.cdc.gov/ncidod/diseases/bacter/typhoid.htm.
 Bacterial Diseases (Other Than Mycoplasma) 33

relatively short period of time, particularly with treatment, it is not a likely cause
of unexplained Gulf War illnesses.

MYCOBACTERIA TUBERCULOSIS
Introduction
Mycobacterium tuberculosis is the primary bacterium responsible for causing
the disease commonly known as tuberculosis (TB). The disease is present
worldwide and is responsible for considerable morbidity and mortality.
Tuberculosis usually exists in the form of a lung infection; however, the
organism may cause disease in any organ or tissue throughout the body. The
tubercule bacillus responsible for the disease is usually transmitted by the
infected individual through coughing or sneezing. Although a single casual
contact may transmit disease, most infections result from sustained exposures.

Epidemiologic Information

Tuberculosis has remained endemic in developing countries; however, it has

reemerged as a major threat to both developing and industrialized countries
over the last decade (Porter and Adams, 1994). Around the world, there are al-
most nine million new cases annually with more than 7,000 deaths per day at-
tributable to TB (Rattan et al., 1998). The emergence of HIV and AIDS as a
global disease has further aggravated the issue because tuberculosis flourishes
in immunosuppressed patients (Daley, 1997; Co, 1994).

What Infected Patients Experience

Clinical signs and symptoms of tuberculosis vary considerably, ranging from a

silent disease to severe systemic infection. For most individuals who contract
the infection, the disease process is almost always silent, being detected only
through familiar TB skin tests or x-ray findings. Occasionally, individuals with a
primary TB infection may have a low-grade fever and mild anorexia. TB may
remain dormant for years or even for a lifetime (Parrish et al., 1998).

Secondary tuberculosis—the phase of the disease that arises in a previously ex-

posed individual—may also be asymptomatic although more commonly it is
accompanied by insidious onset of fever, night sweats, weakness, fatigability,
anorexia, and weight loss. Usually, secondary tuberculosis represents reactiva-
tion of a dormant primary infection, although exposure from exogenous
sources may also occur. When the infection invades and destroys the bronchi,
patients develop a productive cough, often with blood-tinged sputum and oc-
34 Infectious Diseases

casionally frank hemoptysis. When the disease disseminates, patients may ex-
perience differing symptoms and a fever without a clear origin.

Diagnosis

A definitive diagnosis of tuberculosis requires the identification of the tubercule

bacillus. However, most individuals have been tested for tuberculosis using
common TB skin tests (e.g., purified protein derivative, PPD) where the patient
develops an infiltration (swelling) around the sight of antigen injection within
24 hours. A negative skin test, however, does not exclude the possibility of in-
fection and patients with a past history of exposure to TB may have a positive
test without an active infection. Detecting the bacillus by sputum or other cul-
ture is not always simple.

Treatment and Prevention

Preventing TB requires prompt identification and treatment of infected pa-

tients. Family members and close contacts of those found to be infected should
be tested and also treated if they are shown to be positive, even if the infection
is an asymptomatic primary one. A major risk factor for spread of TB is
crowded living conditions and a depressed socioeconomic status.

Correlation with Gulf War Illnesses

The spectrum of disease caused by tuberculosis has been well known for cen-
turies. The disease is recognized throughout the world, including in the Persian
Gulf. It would be almost impossible to not identify some Gulf War veterans with
tuberculosis given the prevalence of the disease in the population. However,
the mechanism of spread, the ability to detect the infection in most individuals
through simple, routinely used skin tests, and the epidemiology of the disease
all suggest that tuberculosis is not the cause of undiagnosed Gulf War illnesses.

Summary

Tuberculosis is a common pulmonary infection commonly caused by repeated

close contact with infected individuals. Primary infection is usually asymp-
tomatic. However, disease reactivation occurs and the seriousness of infection
is much greater in individuals with impaired immune systems (e.g., patients
with HIV and those undergoing immunosuppressive treatments). Although
some Gulf War veterans will undoubtedly be found to have tuberculosis, tuber-
culosis does not appear to be the etiology for the many individuals with undi-
agnosed Gulf War illnesses.
 Bacterial Diseases (Other Than Mycoplasma) 35

ENTERIC AGENTS: ENTEROTOXIGENIC E. COLI, CAMPYLOBACTER,

SHIGELLA, AND OTHER SALMONELLA
Introduction

Infectious diarrhea continues to be a major source of international disease and

death (Murray and Lopez, 1996). Although many of these infections are self-
limited, some are more problematic, causing disability and even death (Frost et
al., 1998). There were a number of outbreaks of diarrhea during Operation
Desert Shield (Hyams et al., 1991). Such outbreaks can be particularly disabling
during periods of deployment because of both the disability they inflict on the
individual and the potential for spread to other individuals.

Epidemiologic Information

Hyams and colleagues collected data from U.S. troops stationed in northeastern
Saudi Arabia between September and December 1990. They cultured stool
from 432 individuals presenting with diarrhea, cramps, vomiting, or hema-
tochezia. They also surveyed 2,022 soldiers in regions throughout Saudi Arabia.
Researchers were able to identify a bacterial enteric pathogen in 49.5 percent of
the troops with gastroenteritis. The most common bacteria were enterotoxi-
genic Escherichia coli and Shigella sonnei.

What Infected Patients Experience

Individuals may experience self-limited mild-to-moderate abdominal cramps

with these infections, or disabling symptoms including diarrhea, cramps,
vomiting, and hematochezia. Common organisms include enterotoxigenic E.
coli, Campylobacter, Shigella, and other Salmonella. Each of these is slightly
different.

Enterotoxigenic E. coli has an incubation period of from one to three days. Fol-
lowing incubation, the illness can be mild to fulminant. Most commonly pa-
tients experience mild, watery diarrhea with abdominal cramps. Vomiting is
present in about half of infected individuals although it rarely is responsible for
major disability. This organism is responsible for what is commonly recognized
as traveler’s diarrhea. The disease resolves with or without treatment; however,
in the most extreme cases, fluid replacement may be necessary.

Campylobacter jejuni is second only to Giardia in the frequency with which it

causes waterborne diarrheal diseases in the United States. After an incubation
period of from two to six days, patients develop fever, cramping, abdominal
pain, and diarrhea that is at first watery but later contains blood and mucus.
36 Infectious Diseases

The diarrhea is usually mild, but not always, and lasts for a few days without
therapy. Sometimes the infection can persist and patients may develop a reac-
tive arthritis that is most commonly associated with patients carrying the HLA-
B27 antigen (Altekruse, 1999).

Shigella produces an acute infectious colitis that is commonly referred to as

“bacillary dysentery.” The spectrum of disease is variable from mild watery di-
arrhea to the fatal dysentery that is more common in less-developed regions.
The incubation period is from one to two days, following which some patients
develop fever, some diarrhea, and some both. Patients with dysentery experi-
ence small-volume frequent stools (several per hour) consisting of blood, mu-
cus, and pus, with abdominal cramps and tenesmus. Most patients recover
over the period of up to a week, although with severe disease, they can suffer
colonic perforation that can prove fatal. Very rarely patients may experience
broader persistent systemic symptoms (e.g., hemolytic uremic syndrome,
arthritis, seizures).

Salmonella are responsible for a number of diseases in humans. In addition to

causing typhoid fever, infection can present as acute diarrhea or in more severe
cases as septicemia, meningitis, reactive arthritis, osteomyelitis, and endo-
carditis. With respect to the gastroenteritis, the incubation period is generally
from one to two days. Diarrhea (sometimes with the presence of blood) may be
accompanied by nausea, vomiting, and abdominal cramps. Generally the ill-
ness is mild and self-limited, although immunosuppressed, elderly, and young
patients are particularly at risk for more severe disease.

Reactive arthritis is a term used to describe joint pain and inflammation follow-
ing exposure to bacterial infections, generally through either the gastrointesti-
nal tract (most commonly following exposure to Yersinia, Salmonella, or
Campylobacter species) or the genitourinary tract (most commonly associated
with chlamydia infections) (Ebringer and Wilson, 2000). Many Gulf War Veter-
ans reporting illness describe joint pain among their findings (Table 1.2).

Typical reactive arthritis patients give a history of infection within three weeks
followed by arthritis in one or several joints. Some cases are accompanied by
other, nonarthritic manifestations. Sometimes the diagnosis is problematic be-
cause of coexisting inflammatory processes and because in about one of four
cases no infectious agent is identified (Nordstrom, 1996). Although sometimes
infectious organisms may be found in the joints, laboratory findings are usually
nonspecific (Beutler and Schumacher, 1997). The disease is usually self limited
and resolves within six months (Nordstrom, 1996). Although some patients de-
velop chronic arthritis, the incidence is believed to be fairly uncommon
(Nordstrom, 1996; Burmester et al., 1995).
 Bacterial Diseases (Other Than Mycoplasma) 37

There is an extremely strong correlation between the risk of reactive arthritis

and the presence of human leukocyte antigen B27 (HLA-B27) (Ebringer and
Wilson, 2000; Beutler and Schumacher, 1997; al-Khonizy and Reveille, 1998;
Braun and Sieper, 1996; Keat, 1999). The HLA-B27 antigen is present in approx-
imately 8 percent of the general population (Ebringer and Wilson, 2000) with a
range of 3 percent to 13 percent in the European population (Olivieri, 1998).
The strength of the association between HLA-B27 can be expressed as the rela-
tive risk (of developing reactive arthritis) given the exposure (the HLA-B27 anti-
gen). The relative risk for this association is 18, an extremely strong association.

Diagnosis

Diagnosis generally requires isolation of the organism from stool. Common

laboratory techniques exist to distinguish known bacterial pathogens that infect
the gastrointestinal tract.

Treatment and Prevention

Treatment depends on identifying the infecting organism and its antibiotic re-
sistance pattern. In reality, most diseases are self-limited, particularly in
healthy infected hosts. Once the bacterial resistance pattern is known, an ap-
propriate antibiotic may be selected for those patients needing more aggressive
therapy. For patients with severe diarrhea, fluid and electrolyte replacement
may be indicated.

Because these are contagious, infectious diseases, prevention centers around

isolation of infected individuals until the disease resolves. Furthermore, good
hygiene contributes considerably to reducing the likelihood of infection.

Correlation with Gulf War Illnesses

Clearly, enteric infections occurred during the Gulf War (Hyams et al., 1991,
1995). This is not surprising given that these diseases are ubiquitous. The most
common organisms identified were enterotoxigenic E. coli and Shigella. The
particular strains were frequently resistant to commonly dispensed antibiotics.
Although these infections occurred in the Gulf and were clearly a major prob-
lem during deployment (Hyams et al., 1991), findings were not unlike those ex-
perienced by civilians and therefore could not account for unexplained Gulf
War illnesses. Some veterans likely suffer from chronic manifestations of reac-
tive arthritis given the number of individuals who served in the Gulf and the
frequency of predisposing genetic risk factors (i.e., HLA-B27). However, most
patients who develop reactive arthritis achieve resolution within months.
38 Infectious Diseases

Summary

Enteric pathogens are ubiquitous organisms known to cause diarrhea, abdomi-

nal pain, and fever. They were clearly present during service in the Persian Gulf
and, in fact, accounted for a major portion of the infectious morbidity soldiers
experienced during service. Most cases were mild. Except in rare cases, infec-
tions with these pathogens were self-limited. They are also easily diagnosed
through common laboratory tests. Therefore, enteric pathogens could not ac-
count for the extended chronic symptoms experienced by those with unex-
plained Gulf War illnesses.

MENINGOCOCCUS
Introduction
Neisseria meningitidis is a gram-negative bacteria that normally populates the
oropharynx (upper respiratory tract) but has the potential to cause a number of
diseases, most importantly meningitis (for which it is named) and bacteremia
in susceptible hosts. Healthy individuals may be carriers of the infection, and
sporadic epidemiologic outbreaks continue to occur in both industrialized and
developing countries.

Epidemiologic Information

Despite what has been learned about the biology and pathogenicity of Neisseria
meningitidis, infection remains a major worldwide public health problem. The
highest percentage of disease is in infants and children. In fact, N. meningitidis
has become the leading cause of bacterial meningitis in this age group (Centers
for Disease Control and Prevention, 1997a). The risk of death from disease de-
pends on a number of factors, including the prevalence of disease, the type of
infection, and the sociodemographic characteristics of the area where infection
occurs (Apicella, 1995). In the United States, an 8–13 percent case-fatality rate
has been reported (Centers for Disease Control and Prevention, 1997a;
“Analysis of endemic meningococcal disease . . . ,” 1976). In some underdevel-
oped countries, fatality can exceed 50 percent among septic patients (Apicella,
1995).

What Infected Patients Experience

The clinical manifestations of N. meningitidis infections are quite variable,

ranging from a transient episode of fever to an overwhelming infection that re-
sults in death. Irrespective of the presentation, the nasopharyngeal infection
that precipitates disseminated disease usually goes unrecognized or is mistaken
 Bacterial Diseases (Other Than Mycoplasma) 39

for a mild respiratory infection. Apicella (1995) reviews the four common
clinical scenarios:

• Bacteremia without sepsis—The patient has a nonspecific upper respiratory

infection or rash. Although the diagnosis may be made by blood culture,
the disease often resolves before the diagnosis is made.
• Meningococcemia without meningitis—The individual shows signs of sep-
sis (elevated white cell count, skin rashes, malaise, weakness, headache,
hypotension) but without meningeal signs.
• Meningitis with or without meningococcemia—These patients have
headache, fever, and accompanying meningeal signs. Cerebrospinal fluid
examination suggests infection.
• Meningoencephalitic—These individuals are septic, obtunded, with
meningeal signs.

With active disease, the signs a patient expresses vary widely. Petechial rashes
measuring from 1–2 mm may be present, particularly on the lower half of the
body. These spots may coalesce to form what appear to be ecchymoses.

Cardiovascular involvement is also well recognized with this infection, with ac-
companying arrhythmias, congestive heart failure, decreased tissue perfusion,
and pulmonary edema. The most devastating findings are septic shock and
diffuse intravascular coagulation (DIC).

Diagnosis

Because the organism commonly colonizes the oropharynx, the mere isolation
of N. meningitidis is insufficient to confirm an infection. In fact, many healthy
individuals harbor this organism. Therefore, diagnosis depends on isolation of
the bacteria from what is otherwise a sterile body environment (e.g., blood,
cerebrospinal fluid (CSF), pleural fluid, pericardial fluid). Bacterial culture is
the standard for diagnosis, although gram-negative diplococci can be seen with
abundant infections on initial Gram’s stain. However, diagnosis is conven-
tionally done by serologic measures through detection of antigens from body
fluids (e.g., blood, joints, CSF). These tests (e.g., latex agglutination, counter-
immunoelectrophoresis) offer accurate rapid diagnosis. These tests also enable
demonstration of the specific serogroup responsible for infection. More re-
cently, use of the polymerase chain reaction has emerged as an additional pow-
erful diagnostic technique for meningococcal infection (Newcombe et al., 1996;
Ni et al., 1992a, 1992b).
40 Infectious Diseases

Treatment and Prevention

Particularly with the development of antibiotic resistant strains of N. meningi-

tidis, efforts have been undertaken to develop vaccines using the bacterial anti-
gens as targets for the vaccine (Oppenheim, 1997; Peltola, 1998; Saez Nieto and
Vazquez, 1997; “Vaccines against meningococcal meningitis . . . ,” 1994; Al-
Aldeen and Cartwright, 1996). In large populations, achieving a sufficient num-
ber of protected individuals creates what is known as “herd immunity” whereby
the risk of epidemics is reduced because the number of individuals harboring
the infection is low, and there are no clusters of infectious individuals. In the
health care setting, it is important to avoid direct contact with potentially infec-
tious individuals, particularly those with a respiratory infection, by adhering to
droplet precautions (Bolyard et al., 1998).

Secondary prevention includes chemoprophylaxis in those with known expo-

sures. Treatment for meningococcal disease has dramatically altered the
course of epidemics. Penicillin, administered either intravenously or intramus-
cularly, remains the first-line treatment.

Correlation with Gulf War Illnesses

Richards and colleagues (1991) confirmed four cases of N. meningitidis infec-

tion during Operation Desert Storm. The clinical manifestations of this disease,
other than the carrier state, are generally quite dramatic, and if a significant
additional population of service personnel was infected, manifestations would
have been apparent and readily diagnosed. The rate of infection among those
serving in the Gulf War is consistent with the rate of infection for adults in the
general population. Service members were vaccinated to provide immunity,
likely contributing to the low rate of infection (Lashof et al., 1996).

Summary

Neisseria meningitidis is a common bacteria that has the potential to cause se-
rious disseminated disease in both an endemic and an epidemic fashion. Diag-
nostic tests exist to detect infection, and four cases were identified during the
Persian Gulf occupation. Although many more individuals who served in the
Persian Gulf could be found to carry the infection in the “carrier state,” the
mere presence of the bacteria does not imply disease. Given the dramatic clini-
cal manifestations of disease (meningitis and sepsis), N. meningitidis could not
account for the unexplained illnesses in Gulf War veterans.
 Bacterial Diseases (Other Than Mycoplasma) 41

BRUCELLA
Introduction
Brucellosis, also known as undulant fever, is a systemic bacterial infection that
in humans results from contact with infected animals or ingestion of infected
animal products, including milk.2 The disease was first recognized over a
century ago during the Crimean War as causing “Mediterranean gastric remit-
tent fever.” Four recognized species result in human disease, including B.
melitensis (the usual animal hosts are sheep and goats), B. abortus (the usual
animal hosts are cattle), B. canis (the usual animal hosts are dogs), and B. suis
(the usual animal hosts are swine). The bacteria is a small, nonmotile, nonen-
capsulated, gram-negative coccobacillus. Brucellosis is an enteric fever that
produces primarily systemic complaints often with associated gastrointestinal
manifestations. Because of the way the bacterium is spread and its worldwide
distribution, it has been responsible for considerable morbidity among humans
and animals.

Epidemiologic Information

Brucellosis continues to be a major source of disease among humans and do-

mestic animals. Incidence and prevalence vary from country to country, al-
though bovine brucellosis, caused mainly by B. abortus, is still the most
widespread infection. In humans, ovine/caprine brucellosis caused by B.
melitensis is the most important clinically apparent disease, particularly in the
Mediterranean, western Asia, and parts of Africa and Latin America (Corbell,
1997). For example, in the southern region of Saudi Arabia, a recent study
found that 19 percent of the population had serologic evidence of exposure to
Brucella antigen, and 2.3 percent of individuals had active disease (Alballa,
1995).

The reported incidence of brucellosis varies from less than 0.01 per 100,000 to
over 200 per 100,000 population (Corbell, 1997). Incidence of infection is high
in some areas, such as Kuwait and Saudi Arabia. Areas where rates appear low
may reflect underreporting rather than actual low incidence of disease. Differ-
ences in various countries may also reflect food preparation customs, public
health measures, including pasteurization of dairy products, and the extent of
contact with potentially infected animals.

______________
2CDC website: http://www.cdc.gov/od/oc/media/brucello.htm.
42 Infectious Diseases

What Infected Patients Experience

Symptom onset, generally starting about two to eight weeks following exposure,
can be either acute or insidious, with equal likelihood. Patient symptoms are
generally nonspecific and include fever, sweats, malaise, anorexia, headache,
and back pain. These nonspecific findings can be misinterpreted as being a
benign viral illness. Without treatment, patients experience an undulating
febrile pattern, hence its common name “undulant fever.” Patients may have
other complaints including depression and an unusual taste in the mouth. Re-
ports of physical findings vary and are more elusive with about 10 percent expe-
riencing lymphadenopathy, 20–30 percent having splenomegaly, and 10–60 per-
cent with hepatomegaly (Young, 1995a, 1995b; Kaye, 1991).

Gastrointestinal symptoms are usually present but may or may not be severe
even though brucellosis is an enteric infection. Usually the generalized findings
predominate. Up to 60 percent of patients report joint problems (Young,
1995a), particularly the hips, knees, and ankles. Bone scans may show inflam-
mation, although definitive radiological evidence of damage is a late finding.
Neurologic manifestations of the disease include meningitis, encephalitis, pe-
ripheral neuropathy, and psychosis. Central nervous system involvement is less
common. A small fraction (2 percent) of patients experience endocarditis al-
though this is the most worrisome manifestation and can be fatal because of
valvular destruction, if not recognized soon enough. Myocarditis and peri-
carditis can also occur. About a quarter of patients have some respiratory
symptoms ranging from those commonly associated with nonspecific viral ill-
ness to bronchopneumonia, lung abscesses, and pleural effusions. Genitouri-
nary findings are unusual but can occur.

A chronic form of brucellosis is recognized when a patient has ill health for a
period of at least 12 months. These individuals have relapsing illness and most
have persisting focal infection, such as in bone, spleen or liver (Young, 1995a).

Diagnosis

Because the clinical presentation is not specific, laboratory confirmation must

be made to arrive at a definitive diagnosis. Routine laboratory tests (e.g., white
cell count) generally do not suggest the presence of a bacterial infection. For
patients with acute disease, blood (or tissue) culture remains the diagnostic
standard (Corbell, 1997; Gad El-Rab and Kambal, 1998; Gaviria-Ruiz and Car-
dona-Castro, 1995). Because the presence of Brucella cannot be demonstrated
through standard culture techniques, serologic tests can be used to establish a
presumptive diagnosis (Gad El-Rab and Kambal, 1998; Barbuddhe et al., 1994;
Barbuddhe and Yadava, 1997; Young, 1991).
 Bacterial Diseases (Other Than Mycoplasma) 43

Prevention

The key to elimination of brucellosis in humans is the eradication, or at least

the control, of the disease in animals. The greater risk is the consumption of
infected animal products, rather than the handling of animals (Cooper, 1992).
Individuals working in higher risk venues, such as farmers, veterinarians, and
other animal health professionals, should receive specific education on hy-
gienic precautions to avoid infection and training to recognize the possibility
that findings might be secondary to Brucella. A safe and effective human vac-
cine is not available at present and those that have been developed have been
fraught with problems (Corbell, 1997).

Correlation with Gulf War Illnesses

Brucellosis is a bacterial infection with a worldwide distribution. Infection oc-

curs by consuming or handling infected animals or animal products such as
dairy products. The CDC reports a fairly high incidence of brucellosis in areas
involved with Operation Desert Storm and Operation Desert Shield. However,
brucellosis is a bacterial disease with a known cause that can be diagnosed by
currently available techniques. Clearly, many of the nonspecific findings asso-
ciated with brucellosis have similarities with undiagnosed Gulf War illnesses;
however, because diagnostic tests exist for brucellosis and veterans have not
shown evidence of infection, brucellosis is not likely to explain the undiagnosed
illnesses in Gulf War veterans. Given the natural prevalence of brucellosis,
some individuals may actually have a chronic infection unrelated to their ser-
vice in the Gulf.

Summary

Brucellosis is a zoonotic bacterial disease that infects humans through contact

with infected animals and animal products, particularly dairy products. The
bacteria have a worldwide distribution, and some species are prominent in the
Middle East. Patients may either present with an acute infection or experience
a more insidious course. Infection usually manifests with a number of nondi-
agnostic findings, including GI, orthopedic, neurologic, cardiovascular, and
pulmonary symptoms. Many of these findings have some similarity to reported
symptoms in patients with undiagnosed Gulf War illnesses. However, brucel-
losis is diagnosable through culture, serologic (presumptive), and molecular
methods. Investigation of ill individuals following Gulf War service has not re-
vealed evidence of infection with this bacterium.
44 Infectious Diseases

CHOLERA
Introduction
Vibrio cholerae is a gram-negative comma-shaped bacterium that has been
known for many years to cause diarrheal illness secondary to intestinal infec-
tion. The infection is frequently mild or asymptomatic, but it can be severe.
Approximately 5 percent of infected persons have severe disease (cholera)
characterized by profuse watery diarrhea, vomiting, and leg cramps. In these
individuals, rapid loss of body fluids leads to dehydration and shock; without
aggressive treatment, death can occur within hours.

Epidemiologic Information

In the United States, cholera was common during in the 1800s. The disease has
been virtually eliminated by modern sewage and water treatment systems.
However, travelers to areas with epidemic cholera may be exposed to the
cholera bacterium.

During epidemics, many individuals excrete large volumes of stool containing

abundant vibrio organisms. This excrement can contaminate the water supply
that is used for washing, drinking, cooking, and swimming.

What Infected Patients Experience

The pathogenicity of cholera results from an enterotoxin that the bacteria pro-
duces. The organism itself does not result in patient illness. The enterotoxin
activates enzymes in the small bowel that result in massive secretion of fluid
into the bowel, overwhelming the normal reabsorptive capacity of the colon.
Patients produce large volumes of dilute, relatively clear diarrhea. Untreated,
patients experience signs of dehydration with dry mouth, recessed eyes, a
thready pulse, lethargy, and anuria. With adequate therapy in the form of fluid
replacement, almost all patients survive. With inadequate treatment, death
rates may approach 50 percent, mostly from dehydration and its consequences.

Diagnosis

When cholera is suspected, definitive diagnosis can be made through microbio-

logic examination of the stool. The organism can be identified by trained mi-
crobiologists on examination of fresh stool, and the bacterium can be cultured
using readily available media. Newer immunologic and molecular mechanisms
now exist to aid in the diagnosis of this disease (Hoshino et al., 1998; Varela et
al., 1994; Hasan et al., 1994; Qadri et al., 1994).
 Bacterial Diseases (Other Than Mycoplasma) 45

Treatment and Prevention

A short-acting vaccine is available for individuals exposed to cholera; however,

the vaccine is not usually recommended for individuals traveling to areas (e.g.,
Latin America) where cholera is commonly found.

Treatment for cholera is supportive, with replacement of fluids and electrolytes

through intravenous and oral therapy. When recognized and treated, patients
recover from their infection without long-term consequences.

Correlation with Gulf War Illnesses

Cholera produces an acute, devastating diarrheal illness that would be hard to

miss. The findings (or lack thereof) in patients with undiagnosed Gulf War ill-
nesses are not consistent with cholera.

Summary

Cholera is an acute diarrheal illness that places the patient at serious threat of
mortality from dehydration if the fluids lost are not properly replaced. How-
ever, with timely treatment, patients recover from the infection without long-
term sequelae. Given the acute nature of the disease, cholera is not consistent
with undiagnosed Gulf War illnesses.