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                                  INFORMATION PAPER
        
                This is to inform you of a viscerotropic form of leishmaniasis
         due to the parasite Leishmania tropica among military personne1
         who deployed to Southwest Asia (SWA) during the Gulf War. To
         date, seven cases have keen diagnosed at Walter Reed Army Medical
         Center. Normally, an infection with Leishmania tropica results in
         cutaneous lesions only; however, all of these cases were free of
         cutaneous lesions and, in each case, the parasite was recovered
         fron the bone marrow. These new cases are distinct from the
         traditional cutaneous form of 1eishmaniasis of which 15 Gulf
         related cases have been diagnosed and treated at Walter Reed Army
         Medical Center.
        
         Epidemiologic risk factors for this viscerotroplc form are not
         well defined at this time. Thesa seven soldiers were members of
         several different Army units widely scattered throughout the SWA
         theater of operations in both field and urban settings. Navy,
         Marine, Air Force and civilian personnel who were stationed
         within the theater of operations are also considered at rtsk of
         exposure .
        
         The natura1 history of this viscerotropic form of L. tropica
         is not known. The fact that it has not been clinically apparent
         in the many travelers to and inhabitants of that region suggests
         that infections are rare, and/or largely subclinical. Based on
         the current cases, the clinical appearance is much less severe
         than that sean in classical viscera1 leishmaniasis (Xala Azar)
         caused by L. donovani. As with other parasitic and infectious
         diseases in the immunosuppressed patient, L. tropica has the
         potential for causing serious illness.
        
         The clinical spectrum for these cases was variable and
         nonspecific. Four of the six symptomatic cases had an acute
         syndrome which included a high fever with rigors and malaise,
         accompanied by mild anemia and low grade elevation of 1iver
         enzymes (AST and ALT). Two cases had a subacute onset, presenting
         with gastrointestinal complaints which included watery,
         facal-leucocyte-negative diarrhea (of snall volumes), nausea, and
         non-focal abdomina1 pain that evolved over time to left upper
         quadrant pain with hepatosplenomegaly. Headaches and chronic
         irritating cough were also seen in some cases. One of the seven
         cases was completely asymptomatic and diagnosed on the basis or
         epidemiologic follow-up of an index case.
        
         Tha incubation period is difficult to accurately measure.
         However, in these cases, the onset of symptoms varied from weeks
         to months after leaving SWA.
        
        A serum Indirect Immunofluorescent Antibody (IFA) test is
        available at Walter Reed Army Institute of Research (WRAIR)
        through the Walter Reed Army Medica1 Center, however, there is no
        commercially available seroloqic test currently available in the
        United States to confirm infection. With this test, in patients
        

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