36 Infectious Diseases

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

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36 Infectious Diseases

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

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

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

Diagnosis generally requires isolation of the organism from stool. Common

Treatment and Prevention

Because these are contagious, infectious diseases, prevention centers around

Correlation with Gulf War Illnesses

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

What Infected Patients Experience

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

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