INTRODUCTION: Military personnel deployed to the theaters of operation in Iraq are subjected to significant levels of dust exposure. Prolonged exposure and inhalation of dust particles and burn pits (where organic material with accelerant are incinerated for security and hygiene purposed) may potentially cause pulmonary symptoms with underlying lung disease. The dust in Iraq is made of a calcium carbonate matrix shell with variable transitional elements as well as organic material in the core; sand generally consists of silicates. While there is some indirect evidence of increased pulmonary symptoms in deployed military personnel, there is scant direct evidence of lung toxicity related to these exposures. We report a case of an adult male, with exposure to burn pits and dust who was found to have exotic foreign material on bronchoalveolar lavage and developed non-specific interstial pneumonitis.
CASE PRESENTATION: A 39 year old active duty male lifetime non-smoker was seen for progressive shortness of breath after minimal exertion (100 feet). He reports that this has been progressing over the last year. Pat medical hisoty was unremarkable. During his military career he has traveled extensively throughout the Middle East and had various assignments. His most recent deployment covered the period 12/05 to 12/06, and duties included being a door gunner in a Blackhawk helicopter where he was frequently exposed to dust. In 11/07 he was still able to meet standards for running times in his age group. PFT’s showed moderate non-reversible obstructive airway disease (FEV1 64%), normal lung volumes and moderate reduction in DLCO. A cardiopulmonary exercise test showed normal VO2 max (93%). RR was not greater than 50, and his anaerobic threshold was achieved (>40%). A methacholine challenge test showed a drop of 30% on his first dose (0.0625 mg). HRCT of the chest showed linear scarring of the lateral lung bases bilaterally and in the lingula including mild air trapping of the right middle lobe and lingula on expiratory images. Additionally, there was no evidence of interstitial pulmonary fibrosis or bronchiectasis. On bronchoscopy no organisms grew and in coordination with the Armed Forces Institute of Pathology specimens were sent for scanning electron microscopy as well as energy dispersive x-ray analysis. Spectral analysis showed small fragments of pulmonary alveolar tissue and bronchial respiratory epithelium, cartilage, and smooth muscle without significant histopathology, except for hemosiderin laden macrophages. There were particles with infrared spectral characteristics of polytetrafluoroethylene (Teflon (r)). Additionally, there were particles containing gold, and particles containing iron, chromium and nickel, thought possibly due to stainless steel. An open lung biopsy showed results consistent with mild focal nonspecific interstial pneumonia. Included in these findings were the presence of silicates and silica.
DISCUSSIONS: This case demonstrates that inhaled material may have a profound effect on lung function in ways heretofore unrecognized. The patient had irreversible obstruction and a normal CPEX with reactive airways, and eventually developed biopsy proven NSIP. Between his redeployment and clinical presentation was a long disease free period. His symptoms occurred gradually after redeployment and were not associated with any other environmental or occupational exposures; no other routinely identifiable etiologies could account for this finding.
CONCLUSION: There is constant environmental exposure by active duty military based on their area of operations in the austere regions of Iraq and Afghanistan. Understanding the relationship of dust exposure, smoking and other potential environmental exposures such as burn pits to the subsequent development of symptomatic and subclinical lung disease is important to document in order to mitigate future exposures.
DISCLOSURE: Darrel Dodson, No Financial Disclosure Information; No Product/Research Disclosure Information