NILS R. VARNEY, PH.D.
DIRECTOR OF TRAINING
IOWA CITY VA MEDICAL CENTER
SUBCOMMITTEE ON BENEFITS,
HOUSE COMMITTEE ON VETERANS AFFAIRS
July 16, 1998
Mr. Chairman I appreciate the opportunity to talk about my research on cerebral malaria in Vietnam Veterans.
Malaria may have afflicted as many as 250,000 ground troops in Vietnam, making malaria nearly as common as gunshot wounds. This statistic is relevant to Vietnam veterans today, because while they may have recovered from the malaria illness itself, a number of these veterans developed cerebral malaria and may have been left with neuropsychological and neuropsychiatric symptoms involving problems with mood, temper and memory which could be mistaken for PTSD.
Let me start with a bit of history. A consistent body of clinical literature dating from 500 BC through the early 20th century has reported that individuals who survive cerebral malaria frequently developed depression, memory loss, personality change, and temper problems as long-term secondary effects of the disease. This constellation of neuropsychiatric deficits was observed often enough among survivors of cerebral malaria in turn-of-the-century, British-occupied India that the syndrome was christened Tropical Neurasthenia. Forrester, a leading expert of his day, reported that cerebral malaria was the single most important cause of mental illness in British-occupied malarial endemic zones. Scores of papers were written about malaria and tropical neurasthenia during the 19th century, and most neurology books of the time contained long sections about cerebral malaria and its neuropsychiatric sequelae. It should be noted in addition that clinical observations about cerebral malaria leading to psychiatric-like symptoms were first recorded in the writings of Hypocrites and Galen, which is 2,000 years before the colonial British experience or the war in Vietnam.
Among the acute brain related complications of cerebral malaria are swelling of the brain with flattening of the cerebral gyri, brain injury from high fever, multiple small hemorrhages throughout subcortical white matter, ring hemorrhages around large blood vessels, blockage of capillaries by "log jams" of blood cells (causing hypoxia in watershed zones of cortex), severe hypoglycemia, and permanent discoloration of the brain to a blue-gray .
The key point from this abundant literature is that malaria, in its severest form, may cause brain damage which may persist after the malarial illness itself has been cured.
In our research, the neurobehavioral status of 40 Vietnam veterans who reported being treated for malaria while in Vietnam was compared with that of a group of combat veterans who sustained gunshot/shrapnel wounds in Vietnam, but did not contract malaria. The purpose of requiring veterans in the comparison group to have been wounded was to control for medical treatment of a non-lethal condition and to ensure that both groups had been exposed to similar levels of combat experience.
The results of the study suggest that cerebral malaria survivors may have multiple neuropsychiatric symptoms which could be problematic years after the acute illness had been "cured." As compared with wounded combat veterans who did not have cerebral malaria, the 40 Vietnam veterans who participated in my study who contracted malaria manifested substantial problems with depressive mood, "personality change," feelings of subjective distress, memory problems, emotional lability, and neuropsychiatric symptoms very similar to small seizures, such as memory gaps and staring spells. Although these findings are statistically and psychometrically more sophisticated and reliable than the clinical observations reported over the previous 2,500 years, our study is only the most recent to suggest that cerebral malaria is a cause of long-standing neuropsychiatric symptomatology in adults who survive the illness.
The message to be drawn from this research is that there may be some Vietnam veterans at risk for suffering from a persistent neuropsychiatric syndrome which can produce a wealth of psychiatric, psychological, neuropsychological, neuropsychiatric and neurological symptoms.
In summary, these findings suggest that further investigation and attempted replication by other groups of independent investigators may be appropriate. If additional studies can confirm that Malaria, or more importantly, the post malaria neuropsychiatric syndrome is a cause of mental problems in Vietnam veterans, then improved treatments could be developed.
It is not my intention to complain about the VA, the Army or Vietnam veterans. Our findings may offer good news for an undetermined number of Vietnam veterans in that they may have mental symptoms which are the result of a neurological disease. With that change in perspective regarding their symptoms, it would logically follow that there would be changes, improvements we hope, in their treatment. In our experience, many of the malaria veterans can be found in PTSD clinics and their lives are substantially improved with neurological treatment.
This concludes my remarks. I would be happy to answer the Committee's questions.