Small Fiber Neuropathy in Veterans With Gulf War Illness

Gulf War veterans deployed to operations Desert Shield and Desert Storm returned with chronic multisystemic symptoms. This Gulf War Illness (GWI) has defied attempts to identify an underlying etiology. Pain and other symptoms attributable to autonomic nervous system (ANS) dysfunction are common, which may suggest a pathophysiologic underpinning. Small fiber neuropathy (SFN) presents with similar symptoms. Toxic exposures have been implicated in both SFN and GWI.

A retrospective chart review of clinical data at the New Jersey War Related Illness and Injury Study Center addressed the following questions: (1) how common was biopsy-confirmed SFN in veterans with GWI; (2) do veterans with GWI and SFN report more symptoms attributable to ANS dysfunction as compared to veterans with GWI and no SFN; and (3) can SFN in veterans with GWI and SFN be explained by conditions commonly associated with SFN? Chart review abstracted GWI status, skin biopsy results, and ANS symptom burden. For veterans with GWI and SFN, additional chart abstraction was explored for commonly reported contributing conditions.

From March 1, 2015, to January 31, 2019, 51 Gulf War veterans evaluated at the War Related Illness and Injury Study center had a skin biopsy. Of these, 42 (83%) were diagnosed with GWI and 24 of 42 (57%) also had SFN. No differences were observed in ANS symptoms when compared with veterans with GWI and no SFN. A potential etiology for SFN was identified in 16 of 24 (67%) veterans with GWI and SFN, increasing to 19 (79%) when hyperlipidemia was included. Our analysis did not identify an explanation in 5 of 24 (21%) veterans with GWI and SFN.

SFN was common in this clinical sample of veterans diagnosed with GWI. A well-established potential etiology was identified in most cases of SFN. About 20% of veterans with GWI in our clinical sample had idiopathic SFN, and it is plausible that deployment-related exposures could have contributed to this condition. Symptoms of ANS are prevalent in GWI, though SFN cannot solely account for this. Our study does not generally support SFN as etiologic for GWI, though this may still be relevant for some. Additional research is required to explore relationships between Gulf War exposures and SFN.