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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