Neurological Manifestations Among US Government Personnel Reporting Directional Audible and Sensory Phenomena in Havana, Cuba

Preliminary Communication March 20, 2018 Randel L. Swanson II, DO, PhD1,2; Stephen Hampton, MD1,2; Judith Green-McKenzie, MD, MPH2,3; et al Ramon Diaz-Arrastia, MD, PhD2,4; M. Sean Grady, MD2,5; Ragini Verma, PhD2,6; Rosette Biester, PhD1,2; Diana Duda, PT, DPT2,7; Ronald L. Wolf, MD, PhD2,6; Douglas H. Smith, MD2,5 Author Affiliations JAMA. 2018;319(11):1125-1133. doi:10.1001/jama.2018.1742 https://jamanetwork.com/journals/jama/article-abstract/2673168?widget=personalizedcontent&previousarticle=2673164&redirect=true editorial comment icon Editorial Comment related articles icon Related Articles multimedia icon Multimedia Editorial Neurological Symptoms Among US Diplomats in Cuba Christopher C. Muth, MD; Steven L. Lewis, MD Medical News & Perspectives More Questions Raised by Concussion-like Symptoms Found in US Diplomats Who Served in Havana Rita Rubin, MA Audio (29:14) Medical Findings In U.S. Government Personnel Reporting Symptoms After Exposure To Sensory Phenomena in Havana, Cuba Full Text Key Points Question Are there neurological manifestations associated with reports of audible and sensory phenomena among US government personnel in Havana, Cuba? Findings In this case series of 21 individuals exposed to directional audible and sensory phenomena, a constellation of acute and persistent signs and symptoms were identified, in the absence of an associated history of blunt head trauma. Following exposure, patients experienced cognitive, vestibular, and oculomotor dysfunction, along with auditory symptoms, sleep abnormalities, and headache. Meaning The unique circumstances of these patients and the consistency of the clinical manifestations raised concern for a novel mechanism of a possible acquired brain injury from a directional exposure of undetermined etiology. Abstract Importance From late 2016 through August 2017, US government personnel serving on diplomatic assignment in Havana, Cuba, reported neurological symptoms associated with exposure to auditory and sensory phenomena. Objective To describe the neurological manifestations that followed exposure to an unknown energy source associated with auditory and sensory phenomena. Design, Setting, and Participants Preliminary results from a retrospective case series of US government personnel in Havana, Cuba. Following reported exposure to auditory and sensory phenomena in their homes or hotel rooms, the individuals reported a similar constellation of neurological symptoms resembling brain injury. These individuals were referred to an academic brain injury center for multidisciplinary evaluation and treatment. Exposures Report of experiencing audible and sensory phenomena emanating from a distinct direction (directional phenomena) associated with an undetermined source, while serving on US government assignments in Havana, Cuba, since 2016. Main Outcomes and Measures Descriptions of the exposures and symptoms were obtained from medical record review of multidisciplinary clinical interviews and examinations. Additional objective assessments included clinical tests of vestibular (dynamic and static balance, vestibulo-ocular reflex testing, caloric testing), oculomotor (measurement of convergence, saccadic, and smooth pursuit eye movements), cognitive (comprehensive neuropsychological battery), and audiometric (pure tone and speech audiometry) functioning. Neuroimaging was also obtained. Results Of 24 individuals with suspected exposure identified by the US Department of State, 21 completed multidisciplinary evaluation an average of 203 days after exposure. Persistent symptoms (>3 months after exposure) were reported by these individuals including cognitive (n = 17, 81%), balance (n = 15, 71%), visual (n = 18, 86%), and auditory (n = 15, 68%) dysfunction, sleep impairment (n = 18, 86%), and headaches (n = 16, 76%). Objective findings included cognitive (n = 16, 76%), vestibular (n = 17, 81%), and oculomotor (n = 15, 71%) abnormalities. Moderate to severe sensorineural hearing loss was identified in 3 individuals. Pharmacologic intervention was required for persistent sleep dysfunction (n = 15, 71%) and headache (n = 12, 57%). Fourteen individuals (67%) were held from work at the time of multidisciplinary evaluation. Of those, 7 began graduated return to work with restrictions in place, home exercise programs, and higher-level work-focused cognitive rehabilitation. Conclusions and Relevance In this preliminary report of a retrospective case series, persistent cognitive, vestibular, and oculomotor dysfunction, as well as sleep impairment and headaches, were observed among US government personnel in Havana, Cuba, associated with reports of directional audible and/or sensory phenomena of unclear origin. These individuals appeared to have sustained injury to widespread brain networks without an associated history of head trauma