The two soldiers deployed to Baghdad who contracted VL presented with fever, enlarged liver and spleen, cytopenia, and hypergammaglobulinemia (Weina et al. 2004). On presentation, one had been deployed for 11 months, and the other had left Iraq 7 months earlier. Examination of bone-marrow biopsies from both patients revealed Leishmania parasites. The patients tested positive for Leishmania in an rK39 serologic test; and, their serum yielded titers of 1:1,024 or greater in a Leishmania immunofluorescent antibody test. Using a PCR assay with species-specific primers, clinicians were able to determine the species—L. infantum-donovani—in one case. The treatment protocols and their outcomes were not published.

Malaria

Very few cases of malaria have been reported in US veterans of the Gulf War, OEF, and OIF. That is not surprising because in 1990-1991, malaria had been eliminated from northeastern Saudi Arabia, where most US troops were stationed, and no indigenous malaria transmission occurred in Kuwait, Bahrain, or Qatar (Hyams et al. 1995a; Oldfield et al. 1991). Malaria due to Plasmodium vivax (vivax malaria) occurred in small numbers in northern Iraq during the late 1980s to 1991 (Oldfield et al. 1991). In the wake of the Gulf War, however, Iraq experienced a serious malaria epidemic; by 2000, vivax malaria had become a serious problem in that country (Schlagenhauf 2003). Moreover, the disease is endemic in many parts of Afghanistan.

Publications during the last 15 years about the threat of vivax malaria to US and allied forces in southwest and south-central Asia sound several consistent themes: the seriousness of the disease, shortcomings of chemical and personal countermeasures, and suboptimal rates of compliance with those countermeasures among troops of many nationalities. According to a 1995 report by the Army Medical Surveillance Activity, “after operations in highly endemic areas, sporadic cases [of malaria] may be expected despite compliance with all prevention guidelines” (MSMR 1995).

Malaria in the Gulf War

Vivax malaria existed in the Euphrates River valley of Iraq in 1990 and 1991 (Young et al. 1992). Seven cases of vivax malaria were reported among US troops who crossed into southern Iraq, where coalition forces operated briefly (Hyams et al. 1995a). No information was given on complications in those troops.

Malaria in Operation Enduring Freedom and Operation Iraqi Freedom

As of May 2005, 52 cases of vivax malaria had been reported in US troops who served either exclusively in Afghanistan or in both Afghanistan and Iraq (Kilpatrick 2005). It is believed that all 52 infections were contracted in Afghanistan, although Plasmodium vivax is endemic in areas of both countries (Wallace et al. 2002). None of the patients was diagnosed with malaria prior to leaving the war theater; this is not surprising, because vivax malaria is known to incubate in human hosts and may relapse up to 5 years after initial infection (Boecken and Bronnert 2005; Johnson 2004).

Thirty-eight of the 52 reported cases of vivax malaria occurred in a 725-man Army Ranger task force deployed to eastern Afghanistan in June-September 2002. Kotwal and colleagues, the primary-care clinicians for these rangers, collected and later analyzed data from the patients during their evaluation, treatment, and followup. In addition, a retrospective anonymous survey was administered to the whole task force in July 2003 to ascertain compliance



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