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Research | Article
Cellular and Humoral Immune Abnormalities in Gulf War Veterans
Aristo Vojdani1 and Jack D. Thrasher2
1Section of Neuroimmunology, Immunosciences Lab. Inc., Beverly Hills, California, USA; 2Sam-1 Trust, Alto, New Mexico, USA Materials and Methods
We examined 100 symptomatic Gulf War veterans (patients) and 100 controls for immunologic
Subjects. Immunosciences Lab., Inc. was
assays. The veterans and controls were compared for the percentage of T cells (CD3); B cells
(CD19); helper:suppressor (CD4:CD8) ratio; natural killer (NK) cell activity; mitogenic response to
requesting immune testing of 10th Army Unit phytohemagglutin (PHA) and pokeweed mitogen (PWM); level of immune complexes; myelin basic
protein (MBP) and striated and smooth muscle autoantibodies; and antibodies against Epstein-Barr
mon symptoms (joint pain, fatigue, headache, virus, cytomegalovirus, herpes simplex virus type 1 (HSV-1), HSV-2, human herpes Type 6 (HHV-
memory or concentration difficulties, sleep dis- 6), and Varicella zoster virus (VZV). The percentage of T cells in patients versus controls was not sig-
turbances, and rash). Haines, with the help of nificantly different, whereas a significantly higher proportion of patients had elevated T cells
medical doctors, initially selected 50 sympto- compared with controls. The percentage of B cells was significantly elevated in the patients versus
matic patients (group A), followed at a later the controls. The NK cell (NK) activity was significantly decreased in the patients (24.8 ± 16.5 lytic
date by an additional 50 symptomatic patients units) versus the controls (37.3 ± 26.4 lytic units). The percentage of patients with lower than nor-
(group B). Medical records and health histories mal response to PHA and PWM was significantly different from controls. Immune complexes were
were not forwarded for us to review. Controls significantly increased in the patients (53.1 ± 18.6, mean ± SD) versus controls (34.6 ± 14.3).
consisted of two groups: group C consisted of Autoantibody titers directed against MBP and striated or smooth muscle were significantly greater in
50 asymptomatic vaccinated veterans of the patients versus controls. Finally, the patients had significantly greater titers of antibodies to the
10th Army Unit who were not deployed to the viruses compared with the controls (p < 0.001). These immune alterations were detected 2–8 years
after participation in the Gulf War. The immune alterations are consistent with exposure to different
50 healthy asymptomatic subjects sent to the environmental factors. We conclude that Gulf War syndrome is a multifaceted illness with immune
laboratory by treating physicians for annual function alterations that may be induced by various factors and are probably associated with chronic
checkups. Patients ranged from 34 to 56 years fatigue syndrome. Key words: autoantibodies, B cell, Gulf War syndrome, immune complexes, nat-
ural killer cell, T cell. Environ Health Perspect 112:840–846 (2004). doi:10.1289/ehp.6881 available
26 females. The controls were age and sex via http://dx.doi.org/ [Online 17 February 2004]
matched. Venous blood was received within24 hr from different clinics from several statesand immediately processed for immunologic increased rate of amyotrophic lateral sclerosis testing. Groups A and C underwent immuno- 1990–1991 described multiple-organ symp- (ALS) (Haley 2003; Horner et al. 2003).
logic testing in 1993. The testing of groups B Moreover, Gulf War Veterans have an increase and D occurred over an extended period from chronic fatigue, fibromyalgia, neurocognitive in serum RNAs with segments homologous to 1995 through 1999. The tests were done at no deficits, irritable bowel syndrome, headaches, charge to the U.S. Army and as a result were joint pains, fever, and a general unwellness, rearrangement of this antigen-responsive spot below. The test requests were properly docu- (Cherry et al. 2001; Gray et al. 2002; Haley mented and kept in a confidential file. All sub- similar to those of chronically ill individuals jects gave their informed consent and allowed Persian Gulf Study Group 1997; Kang et al.
with immunologic alterations after exposure inclusion of their data in this report without to chlorinated pesticides (McConnachie and disclosure of their identity in the publication.
Cassells 1998). GWS probably has a multiple- Zahalsky 1991, 1992), chlorpyrifos (Thrasher Basic laboratory tests. Patients and con-
factorial etiology involving possible chemical et al. 1993, 2001), formaldehyde (Thrasher exposures (Haley and Kurt 1997). The sus- et al. 1987, 1990), silicone breast implants (CBC); chemistry, including lipids, liver pected factors include Arabian sand dust, (Vojdani et al. 1993), and solvents (Vojdani enzymes, thyroid function [triiodothyronine low-level chemical and biological warfare et al. 1992). Reported immunologic abnor- agents, pyridostigmine bromide, N,N-diethyl- malities suggest a shifting of the immune sys- m-toluamide, organophosphate pesticides, Address correspondence to A. Vojdani, Immuno- sciences Lab. Inc., 8693 Wilshire Boulevard, Suite depleted uranium, combustion by-products of 200, Beverly Hills, CA 90211 USA. Telephone: oil well fires, diesel exhaust, petroleum prod- Rook and Zumia 1997; Zhang et al. 1999).
(310) 657-1077. Fax: (310) 657-1053. E-mail: ucts, and infectious agents (Abou-Donia et al.
Moreover, levels of complement components 2001; Kurt 1998; Moss 2001; Schumm et al.
(C3a, C4a, C5a) are significantly increased in Portions of this study were presented by testimony 2002; Sharabi et al. 1991). Explanations for chronic fatigue syndrome (CFS) patients ver- of A.V. before the Senate Subcommittee on Veterans GWS include genetic polymorphism of para- sus controls (Sorensen et al. 2003). As a Affairs 16 November 1993 and the PresidentialSpecial Oversight Board 19 October 1999.
The contents of this article are solely the responsi- et al. 2001), butyrylcholinesterase (Shen 1998), matic GWS patients to determine if they had bility of the authors and do not necessarily represent glutathione S-transferase and cytochrome immunologic alterations similar to those seen the official view of the U.S. Army or U.S. government in CFS (Levine et al. 1998; Patarca 2001; recently, neuropathy target esterase (Winrow Rosenbaum et al. 2002), chemically exposed The authors declare a competing financial interest et al. 2003). Clinical findings include abnor- individuals (Baj et al. 1994; Cooper et al.
in that this study was conducted with no charge to thesoldiers. Also, A.V. is a co-owner of the laboratory, malities of basal ganglia and brainstem (Haley 2002; Griem et al. 1998; Thrasher et al.
and J.D.T. serves as a paid consultant.
et al. 2000) and recently reported increased 1993; Vojdani et al. 1992), and earlier reports Received 28 November 2003; accepted 17 February neurologic diseases and, particularly, an VOLUME 112 | NUMBER 8 | June 2004 • Environmental Health Perspectives Article | Immune abnormalities in Gulf War veterans (T3), thyroxine (T4), thyroid-stimulating hor- lytic units (LU), calculated as described by to each well. Plates were incubated for 1 hr at room temperature and read in a microtiter nuclear antibody (ANA), rheumatoid factor Lymphocyte mitogenic assay. Lymphocytes
reader at 480 nm wavelength. We plotted a were isolated and tested for mitogenic activity titration curve using rabbit antisera, and com- Lymphocyte subset enumeration. Direct
as described by Fletcher et al. (1992) and pared patient and control sera with this stan- immunofluoresence staining of cell surface Maino et al. (1995). Briefly, 5 × 105 lympho- dard curve. Results are expressed by the ELISA antigen was accomplished using the Becton- cytes per 0.1 mL CM were cultured in flat- (enzyme-linked immunosorbent assay) values.
bottom microtiter plate wells. Cells from Striated and smooth muscle antibody assay.
system (San Jose, CA). The peripheral mono- patients and controls, as well as cells with We purchased skeletal muscle myoblast cell nuclear cells are treated with monoclonal anti- known mitogenic stimulation, were cultured line CRL-1769 and smooth muscle cell line bodies conjugated to fluorescein isothiocyanate with or without an optimal concentration of Culture Collection (Rockville, MD). Cells samples were first treated with red blood cell were grown in Dulbecco’s modified Eagle’s medium (90%) and fetal bovine serum (10%).
stained with monoclonal antibody, and then After 7 days in culture, the cells were harvested, analyzed with the FACScan flow cytometer.
48 hr of incubation, the cells were harvested sonicated, and used for coating ELISA plates.
and stained with CD69 monoclonal antibody Each ELISA microplate well was coated with PE-conjugated monoclonal antibodies: CD45/ conjugated to fluorescent dye and analyzed by 100 µL cell lysate containing 10 µg protein in 0.1 M carbonate buffer (pH 9.5). Plates were for T-helper cells, CD3/CD8 for suppressor added (negative control) provided information incubated overnight at 4°C and then washed about the media and cells used in the assay so three times with 200 µL Tris-buffered saline we could determine possible nonspecific mod- ulatory activity. Values for patients and con- the exception of goat anti-human IgG F(ab´)2, these sets of monoclonal antibodies, we deter- trols were compared with the daily negative all other steps were similar to the MBP ELISA mined the percentage of positively stained cells and positive control for each assay. Results method described above. To detect nonspecific for each marker pair and the percentage of were calculated using the following formula: binding, we used all reagents except human serum in several control wells and coated some Percentage of stimulation = Preparation of peripheral blood leukocytes.
wells with different tissue antigens.
Leukocytes were prepared from heparinized Immune complexes. We measured IgG,
Activated control – Unstimulated control density gradient (Sigma Chemical Company, microtiter plates with anti-C1q. Addition of St. Louis, MO). Cells were washed three times serum, second antibody, and substrate was with Hanks balanced salt solution and resus- We estimated three stimulation levels: low, pended to a concentration of 107 cells/mL in a < 75% of the number of control cells; normal, 75–125% of the number of control cells; and Antibodies to viruses. Antibody titers
RPMI-1640 supplemented with 10% fetal calf elevated, > 125% of the number of control against Epstein-Barr virus (EBV); cytomegalo- serum and 1% antibiotics (100 U penicillin and 100 µg/mL streptomycin). We examined Myelin basic protein antibody. The anti-
(HSV-1), HSV-2, HHV-6; and Varicella zoster purity of the cells by flow cytometry using was analyzed as previously described (Vojdani was > 95%. Cells were used for different func- et al. 1992). Briefly, MBP (Sigma Chemical Determination of expected ranges. We
tional assays within 1 hr of isolation.
Co.) was checked for purity by polyacrylamide NK cell cytotoxicity assay. We used a stan-
gel electrophoresis (Diebler et al. 1972).
dard 4-hr 51Cr-release assay (Whiteside et al.
Antisera to MBP were induced in rabbits by 1990) to determine NK cell cytotoxicity.
repeated injection of the protein in complete Dickinson) carried out in-house verification Briefly, we added 1 × 104 51Cr-labeled K562 Freund’s adjuvant. Antibody activity in the using blood from 100 healthy controls from tumor target cells in 0.1 mL CM to different rabbit sera and the patient and control samples wells of a microtiter plate. Effector cells were was detected by adding different dilutions then pipetted into triplicate wells for each dilu- tion to give effector:target ratios of 6:1, 12:1, microtiter plate previously coated with MBP.
• The manufacturers of the immune complex 24:1, and 48:1. After a 4-hr incubation at MBP (250 µg/mL) was dissolved in carbonate 37°C, the plates were centrifuged at 1,400 rpm buffer (pH 9.6), and 200 µL of this solution expected range with their products (Abbas et for 4 min, and 0.1 mL of supernatant was col- was added to each well. After incubation, al. 1994, Christenson et al. 1992, Matheson lected from each well and placed in a gamma et al. 1990, Shehab and Brunell 1983).
counter. The percentages of isotope released serum albumin plus gelatin, 200 µL of either • We obtained expected ranges for NK cell were calculated using the following formula: diluted rabbit or human serum was added to activity from Whiteside et al. (1990) and the wells. Incubation was repeated for 1 hr at 25°C, and the sera were shaken out of the wells, which were then washed five times with • We determined expected ranges for PHA and conjugated goat anti-rabbit or goat anti- PWM mitogenesis and for autoantibodies to human IgM (optimal dilution) was added to the appropriate well. After incubation and house using 100 healthy controls for which effector:target ratio was expressed in terms of repeated washing, 200 µL substrate was added means, SDs, and 95% CIs were calculated.
Environmental Health Perspectives • VOLUME 112 | NUMBER 8 | June 2004 Thus, the expected ranges are a combination patients are listed in Table 1. The ratio was index < 75% of expected (p < 0.01) but 4% of of suppliers’ recommendations and in-house significantly (p < 0.001) elevated in patients patients had a stimulation index > 125% (p < 0.05). For PWM stimulation, an increased Statistics. We used two-sided critical t-tests
controls (1.74 ± 0.34). The Z-values for the percentage of patients had an index < 75% percentage of patients with values outside the (p < 0.01), whereas the difference between the Z-tests for comparison of independent propor- expected distribution of the CD4:CD8 ratio percentages of patients (4%) and controls (1%) tions as described by Bourke et al. (1985).
were significantly different compared with with values > 125% were not significant.
those of the controls (p < 0.001). Autoantibodies. The observations for IgM
NK cell activity. The data obtained for
anti-MBP in the controls and patients are Basic laboratory tests. We observed some vari-
NK lytic activity are presented in Table 2. The shown in Table 3. The mean ELISA units for ations from expected normal ranges in both lytic activity was significantly less (p < 0.001) IgM antibodies were significantly (p < 0.001) controls and patients, respectively, as follows: in patients (24.8 ± 16.5) than in controls greater in patients (45.9 ± 35.8) than in con- (37.3 ± 26.4). The percentages of individuals trols (28.4 ± 13). The Z-value for the percent- 9%; lipid profile, 18 and 22%; liver enzymes, with > 50 LU were not different between the age of patients with > 50 ELISA units was two groups (p = not significant), whereas the significant (p < 0.001). The mean value for p-value for the percentage of patients with the patients with IgM titers > 50 ELISA units immunoglobulins, 6 and 8%. Z-tests for < 20 LU was significant (p < 0.01).
independent proportions revealed no signifi- Mitogen stimulation. The results of PHA
Antibodies to muscle (striated and smooth).
cant difference between controls and patients and PWM stimulation of peripheral lympho- The results for IgG antibodies to both smooth cytes in the controls and patients are summa- and striated muscle are shown in Table 3. The Comparison of patients (groups A and B)
mean IgG titers observed in the patients (42.8 and controls (groups C and D). We analyzed
± 72.3) were significantly (p < 0.001) greater the data to determine if differences existed different between controls and patients.
than those for the controls (15.9 ± 11.4).
However, the distribution of stimulation values Immune complexes. The observations on
controls for each tested immune parameter did differ between the two groups. For PHA, (data not shown). No significant differences more GWS patients (32%) had a stimulation blood of controls and patients are summarized were found; therefore, we combined patientgroups A and B and control groups C and D Table 1. Percentage of CD3 T cells and CD19 B cells and CD4:CD8 ratios in controls and patients.
for further statistical analysis. In addition, we Percent of subjects outside the expected range observed no differences between males and CD3 T cells. The percentages of CD3
T cells present in the peripheral blood of con- trols versus patients are presented in Table 1.
The mean percentage of CD3 cells in patients higher compared with the controls (71.6 ± 7.3%), but the difference was not significant.
However, the percentage of individuals that fell outside of the expected range of 53–79% groups; 2% of controls and 9% of patients had < 53% CD3 cells, and 5% of controls and 30% of patients had > 79%. The critical Controls and patients were compared using Student’s t-test. Critical Z-values were obtained for the normal distribution.
Z- and p-values for variance from normal dis-tribution were significant (p < 0.05).
Table 2. NK cell activity and lymphocyte stimulation with PHA and PWM in controls and patients.
CD19 B cells. The percentages of CD19
B cells present in the peripheral blood of con- trols versus the patients are presented in Percent of subjects outside the expected range Table 1. The mean percentage of B cells in thepatients (16.1 ± 6.0%, mean ± SD) was greater than that for the controls (11.5 ± 3.1%). The difference between the two means was highly significant (t = 11.402, p < 0.001). The distrib- ution of B cells outside of the expected range (5–15%) was also different when the patients were compared with the controls. Forty-nine percent of patients and 5% of controls had > 15% B cells, whereas 0% of controls and 4% of patients had < 5% B cells. The critical Z-values for variance from normal distribution were significant (p < 0.01).
CD4:CD8 ratio. The CD4:CD8
(helper:suppressor) ratios for controls and NS, not significant. Controls and patients were compared using Student’s t-test and Z-test. VOLUME 112 | NUMBER 8 | June 2004 • Environmental Health Perspectives Article | Immune abnormalities in Gulf War veterans in Figure 1. Immune complexes were signifi- groups (Table 2). Such an analysis is appropri- cantly (p < 0.001) elevated in the patients ate because immune dysregulation can result in trols (34.5 ± 14.3 mEq/mL) (Figure 1A). In response in some individuals. Mitogen stimula- addition, the percentage of patients with ratory testing (CBC, chemistry, T3, T4, TSH, tion is used clinically to assess cellular immunity immune complexes > 50 mEq/mL was signifi- in patients with immunodeficiency, cancer, and cantly higher than that for controls (p < 0.01) between patients and controls were not signif- autoimmunity, as well as to assess the immuno- icant. Therefore, we conclude that such tests toxic potential of drugs and chemicals in Antibodies to viruses. The results obtained
are of little value in diagnosing GWS.
humans and experimental animals (Smialowicz on antibodies to viruses are presented in 1995). Similarly, assessment of NK lytic activity Table 4. Mean titer levels for each virus were field of immunotoxicology is the degree of per- also gives valuable information. The lytic activ- significantly (p < 0.001) higher in the patients turbation to a given parameter after exposure ity of NK cells (Table 2) was significantly lower to a xenobiotic that translates into a significant in the GWS patients (24.8 ± 16.5) versus the health risk. A number of methods have evolved controls (37.3 ± 26.4). This was also reflected between the patients and controls resulted to address the question of how a chemical or by an elevated number of GWS patients (47%) from a disproportionate number (percentage) drug affects the ability of the immune system with low lytic activity of NK cells. Decreased of patients who had elevated titers to each to resist challenge by pathogens or abnormal numbers of NK cells have been reported in virus. For example, the mean IgM antibodies host cells (e.g., tumor). These include both GWS individuals with chronic fatigue (Zhang to EBV viral capsid antigen (VCA) was 724 functional (i.e., activity of one or more specific et al. 1999). Furthermore, decreased mitogene- ± 401 ELISA units for the 56 individuals that cell types) as well as host resistance assays. They were designed to evaluate the overall changes reported after exposure to xenobiotics and in 300 ELISA units. Similar observations were in the functional integrity of the immune sys- chronic fatigue (Heuser and Vojdani 1997; evident for each of the remaining viruses.
tem associated with certain chemicals, pharma- Levine et al. 1998; Racciatti et al. 2001; Z-values for the percentage of patients with elevated titers were significantly different (Cornacoff et al. 1995; Loveless et al. 1997; Friberg 1998). Thus, the observed changes in Luster et al. 1988, 1993; Smialowicz et al.
the functional status of T-, B-, and NK cells in 1995). Therefore, analysis of circulating lym- Discussion
phocyte subpopulations reveals that alterations alterations in humans after exposure to xeno- The patients and the controls that underwent do exist in increased T-cell numbers, B-cell immunologic testing were from two different time periods, 1993 versus 1995–1999. In addi- immunosurveillance is whether information tion, the two sets of controls were different: ratio indicates an increase in inducer helper one consisted of asymptomatic U.S. Army sol- diers who did not serve in the Gulf War, and cells. These observations are compatible with predict future development of cancer or auto- the other consisted of healthy individuals previous reports on GWS (Zhang et al. 1999) immune diseases. Indications of the significant undergoing annual checkups. Therefore, we as well as those regarding lymphocyte subset role for NK cells in preventing the develop- deemed it necessary to determine if there were alterations after exposure to xenobiotics (Baj ment of cancer in both mice and humans have any differences between the groups. t-Tests et al. 1994; McConnachie and Zahalsky 1991, been reported (Imai et al. 2000; Wilson et al.
comparing the means of each immune parame- 1992; Thrasher and Broughton 2001; Vojdani 2001). A prospective cohort study among a ter revealed that no differences existed between the two sets of patients as well as the two sets medium and high cytotoxic activities were of controls (data not shown), permitting the of GWS patients was done by measurement of associated with reduced cancer risk, whereas pooling into patients (n = 100) versus controls T- and B-cell function and NK cell activity.
low activity was associated with an increased (n = 100). This analysis revealed two interest- risk (Imai et al. 2000). Wilson et al. (2001) ing observations: a) GWS patients had response to PHA and PWM were not different immunologic alterations approximately 2–8 in patients versus controls, the percentage of years after participation in the Gulf War; and individuals with abnormally low mitogenesis b) the asymptomatic soldiers’ immunologic was significantly different between the two Table 3. IgM antibody against MBP and IgG antibodies against smooth and striated muscle in controls and
patients.
Level of C1q immune complexes mEq/mL
Percent elevation of C1q immune complexes
Figure 1. Total level of immune complexes (A) and
percentage of elevation (B) in controls and patients with GWS. Error bars indicate SD. Controls and patients were compared using Student’s t-test.
Critical Z-values were also obtained for normal dis- Controls and patients were compared using Student’s t-test and Z-test. tribution; p < 0.01, Z = 5.58, t-test = 7.46. Environmental Health Perspectives • VOLUME 112 | NUMBER 8 | June 2004 demonstrated suppressed NK cell activity with generate a variety of substances associated with altered host resistance in mice. NK cell activity et al. 1986). Thus, it would appear from these muscle damage and the acute phase response, was incrementally decreased by intravenous observations on increased immune complexes activating the classic pathway of complements in the patient population in the present study receptors. After a ≥ 80% decrease in sponta- that inflammation and autoimmune reactions neous NK activity, a challenge with ≥ 1 × 103 determine if an increase in antibodies to several B16F10 melanoma cells resulted in increased HSV types was present (Table 4, Figure 2). The tumor burden in the lungs (Wilson et al.
data clearly show that significantly increased 2001). Furthermore, when challenged with1 × 105 melanoma cells, tumor burden was Table 4. Titer levels of antibodies to viruses found in controls and patients (expressed in ELISA units).
not increased until spontaneous NK activity had been decreased by ≤ 50–60%. Altered host resistance is a function of both the mag- nitude of the decrease in NK activity and the Increased levels of autoantibodies to vari- ous organs in humans, including MBPs, have been reported after exposure to toxic chemi- VCA, viral capsid antigen. Controls and patients were compared using Student’s t-test. cals (McConnachie and Zahalsky 1991, 1992;Thrasher et al. 1987, 1990, 1993; Vojdani et al. 1992, 1993). Thus, the increased inci- dence of antibodies to MBP and striated and smooth muscle (Table 3) in the GWS patientsis suggestive of autoimmunity, possibly result-ing in tissue injury from toxic chemical expo- sure (Cooper et al. 2002; Griem et al. 1998).
The presence of IgM antibodies to MBP appears to indicate that an active processinvolving release of these self-antigens is occur-ring up to 8 years after injury. Central nervous Percent elevation
system injury has been reported in researchanimals exposed to pyridostigmine bromide, DEET (N,N-diethyl-m-toluamide), and per-methrin (Abou-Donia et al. 2001) and insome GWS patients, in particular, ALS (Haley 2003; Horner et al. 2003). The observations presented here suggest that additional studies Figure 2. Percent elevation above the expected range of viral antibodies in controls and patients with
are needed on neural damage and/or axonal demyelinization in symptomatic Gulf Warveterans. Neural antigen and MBP antibodies have been reported in patients with neurologic No immune
disorders (Terryberry et al. 1998; Willison and abnormalities
symptoms
Yuki 2002), including ALS (Rogers et al.
1996), autism (Vojdani et al. 2002), and mul- tiple sclerosis (Vojdani et al. 2003). Therefore, our results are consistent with the excess of alteration
Environmental
dysregulation
were found to have significantly elevated cir- function
culating immune complexes (Figure 1).
previously reported to our knowledge in GWS patients. Circulating immune complexes are Chronic fatigue
formed by excessive antigen antibody reaction.
dysfunction
syndrome
numerous immunopathologic conditions,including systemic lupus erythematosus,rheumatoid arthritis, glomerulonephritis, and Figure 3. Hypothetical description of GWS in relation to environmental factors present in the Gulf War and
infectious induced inflammation (Abbas et al.
their effects on individuals with no genetic susceptibility to chemicals versus those with genetic polymor-phism and susceptibility to chemicals resulting in immune function abnormalities and possibly immune 1994). Deposition of immune complexes can dysregulation. Only in the subpopulation susceptible to these environmental factors may these immune occur from cell- or tissue-specific antibody– abnormalities result in viral reactivation and symptoms similar to those of chronic fatigue and fibro- antigen reactions, resulting in organ injury myalgia. PAH, polycyclic aromatic hydrocarbons.
VOLUME 112 | NUMBER 8 | June 2004 • Environmental Health Perspectives Article | Immune abnormalities in Gulf War veterans antibody titers occurred in the GWS patients between genes and environmental stressors Haley RW, Kurt TL. 1997. Self-reported exposure to neurotoxic compared with the controls for each virus tested (Waters et al. 2003). This new knowledge of chemical combinations in the Gulf War. A cross-sectionalepidemiologic study. JAMA 277:231–237.
toxicogenomics may enable us to answer why, Haley RW, Marshall WW, McDonald GG, Daugherty MA, Petty VZV; Table 4). When the observations were upon exposure to these environmental factors, F, Fleckenstein JL. 2000. Brain abnormalities in Gulf War limited to only affected individuals, the some soldiers developed GWS and others did syndrome: evaluation of 1H NMR spectroscopy. Radiology increased titers to each virus was even more evi- not. Finally, it appears that additional studies Hallman WK, Kipen HM, Diefenbach M, Boyd K, Kang H, dent (Figure 2). Exactly when the viral infec- Leventhal H, et al. 2003. Symptom patterns among Gulf veterans versus symptomatic Gulf War veter- War registry veterans. Am J Public Health 93:624–630.
these data. However, the increased IgM anti- ans would be beneficial in further understand- Heuser G, Vojdani A. 1997. Enhancement of natural killer cell activity and T and B cell function by buffered vitamin C in bodies to EBV VCA suggest that reactivation of ing the immunologic observations presented patients exposed to toxic chemicals: the role of protein EBV is probably occurring and may involve the kinase-C. Immunopharmacol Immunotoxicol 19:291–312.
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VOLUME 112 | NUMBER 8 | June 2004 • Environmental Health Perspectives

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