Dr. Nicolson said he would approach the problem of MCS from a biological direction. His involvement with Gulf War illness began when his daughter (who was serving there) experienced symptoms, but could find no help for them. She became unable to continue with pilot training in the Army and changed careers to medicine. In the process of trying to help her, Dr. Nicolson became involved in a large project on the diagnosis of chronic infections in a variety of fatiguing and autoimmune illnesses, including GWI.

Chronic infections by themselves can create illness, but they seem to act in conjunction with other factors, such as chemical and environmental exposures. Multiple biologic exposures also play a role in creating chronic illness. So does genetic predisposition, but little is known about this. Dr. Nicolson hypothesizes that a variety of bacterial and viral infections play an important role as causative agents, cofactors, or opportunistic infections. Together they provide an important source of morbidity in patients with a chronic illness. These infections are often opportunistic, as patients with chronic illness resulting from environmental or chemical exposures are more susceptible to them. He said that he did not intend to argue whether or not they are the sole cause.

Dr. Nicolson and his colleagues conducted a study of the signs and symptoms of 650 Gulf War veterans beginning in the early 1990s, before the media frenzy about GWS began. Dr. Nicholson commented that the label "Gulf War syndrome" presumed that medicine knew more than it did about the illnesses associated with the Gulf War. A survey form was distributed to veterans of the Gulf War, asking about signs and symptoms before, during, and after the war; where they served; what previous diagnoses they had had; their illness state; their environmental exposures; their vaccination record; what treatment they had had; and the condition of their family members. At the same time, a U.S. Senate survey was studying 1,200 families of Gulf War veterans, as there were indications that symptoms were spreading to family members. In this study, approximately 77% of spouses and 65% of children born after the war showed similar signs and symptoms to patients with GWI.

In the Gulf War there was a variety of potential toxic exposures: chemicals, radiologic exposures (and not just to depleted uranium); environmental exposures like sand and smoke; and biological exposures.

Many of the signs and symptoms of biological exposures are not easily separated from those of chemical exposures. The biological exposures are of particular interest because of the spread of illness to families. Nicolson and his colleagues focused on mycoplasma species, theorizing that these could lead to family members becoming sick. Family members would not likely become sick through handling the veterans= equipment, or if the illness was due to PTSD. The estimate is that at least 40% of GWI may be due to specific biological exposures such as mycoplasmal infections; so mycoplasmal infections do not explain everything, but could be a subset that causes illness to spread to families. Sixty families were studied. Most, but not all, the children were symptomatic and showed similar signs and symptoms as the family member who was a veteran. When the illness was passed to families there was a high incidence of similar infection found in every symptomatic family member.

Abnormalities in the patients= immune functions were seen in laboratory tests. Some tests are difficult to do and are not well known. Infections of a subclass of mycoplasma were seen (Mycoplasma fermentans), which interferes with cell metabolism. It can only be detected using molecular tests and is usually misdiagnosed, left untreated, or treated inappropriately. The types of infection reported in Gulf War veterans and people with chronic problems (usually mycoplasma, chlamydia, and other chronic bacterial and viral infections) do not usually stimulate an immune response, so there is no point looking for antibodies. These infections can be found using a polymerase chain reaction (PCR) that amplifies a small, unique sequence of DNA. It is important that the sequence of the PCR product from each patient be confirmed by a back-hybridization reaction, something few other laboratories do.

Approximately 40% of the Gulf War veterans tested positive for any species of mycoplasma, and of these more than 80% were positive with Mycoplasma fermentans. Two different laboratories confirmed this. Of CFS and FM syndrome sufferers, more than 60% were infected with mycoplasma, but in contrast to the Gulf War veterans, these patients could have one or more species often different from Mycoplasma fermentans. Those who had been sick over a decade had multiple mycoplasmal infections, often along with other infections such as chlamydia. Those who had been sick for less than three years usually had one type of infection. These infections played a role in keeping the patients sick. It was shown that fewer than 8% of the long-term patients recovered fully without direct treatment of their chronic infections. Mycoplasmal infections and multiple infections caused by other bacteria also play a role in rheumatoid arthritis.

The reason these findings have not been seen before is that no one has looked for multiple infections. Molecular tests were also not available before. With molecular testing, reproducibility can be a problem and confirmation is necessary because of interfering agents in the blood; therefore, the DNA has to be purified first. Stability is extremely important in looking at the samples.

The Armed Forces Institute of Pathology claimed that no GWI sufferers tested positive for Mycoplasma fermentans. It could be that the laboratories were not keeping their samples at the appropriate temperature, because three other laboratories, including Dr. Nicolson’s, found mycoplasmal infections in fresh blood samples at approximately the same incidence (about 40%) in patients with GWI.

Dr. Nicolson recommended six-week cycles of antibiotics (doxycycline) as treatment. Mycoplasmal infections are difficult infections to treat because they are slow growing and they are found inside cells. Multiple cycles of antibiotics are required. After one cycle, 100% of the veterans relapsed. Most recovered after several cycles. Those who did not recover seemed to be in the group who were sensitive to chemicals. Once they had recovered, patients reported that they were no longer as sensitive to chemicals, so there is a role for biologic agents in the process of chemical sensitivities.

Many patients have nutritional problems such as those caused by poor nutrient uptake and irritable bowel syndrome. Diet is very important in recovery, and the antibiotic treatment has to be complemented with dietary supplements. To control fungal and yeast infections, patients must avoid refined sugars and alcohol, stay active, take saunas, and follow nutritional recommendations for boosting their immune systems.

In a three-year follow-up of civilians with CFS, 80% of patients with confirmed mycoplasma infections responded, and more than 60% had recovered using the antibiotic and dietary regimen proposed by Dr. Nicolson.

Asking what potential role mycoplasma could play in disease, and whether it could cause disease, Dr. Nicolson listed these 1996 criteria:

• high incident rate
• high recovery rate
• antibody response
• clinical response suppresses the infection
• antibiotic response (Dr. Nicolson noted an adverse reaction to penicillin in patients not previously sensitive to it.)
• animal models (Monkeys infected with Mycoplasma fermentans developed a smouldering disease as in humans and then died, as did rodents. Veterinarians understand the role of mycoplasmas in animal illnesses.)
• human testing (as in the Texas prison system)
• antibody protection

In discussing where Gulf War veterans could have contracted these infections, Dr. Nicolson mentioned vaccines. Mycoplasma is a common contaminant found in 6% of vaccines. Some non-deployed veterans receiving multiple vaccines have similar symptoms to those of deployed veterans. Adverse reactions to the anthrax vaccine were reported by 50% to 60% of people vaccinated, but many did not report until after the 48-hour reporting time. There is also the possibility of vaccine failure.

In closing, Dr. Nicolson said that he does not know how MCS "fits into the picture."