Occupational Lung Diseases among Soldiers Deployed to Iraq and Afghanistan

Abstract

Military personnel deployed to Iraq and Afghanistan, from 2004 to the present, has served in a setting of unique environmental conditions. Among these are exposures to burning trash in open air "burn pits" lit on fire with jet fuel JP-8. Depending on trash burned--water bottles, styrofoam trays, medical waste, unexploded munitions, and computers--toxins may be released such as dioxins and n-hexane and benzene. Particulate matter air pollution culminates from these fires and fumes. Additional environmental exposures entail sandstorms (Haboob, Shamal, and Sharqi) which differ in direction and relationship to rain. These wars saw the first use of improvised explosive devices (roadside phosphate bombs),as well as vehicle improvised explosive devices (car bombs), which not only potentially aerosolize metals, but also create shock waves to induce lung injury via blast overpressure. Conventional mortar rounds are also used by Al Qaeda in both Iraq and Afghanistan. Outdoor aeroallergens from date palm trees are prevalent in southern Iraq by the Tigris and Euphrates rivers, while indoor aeroallergen aspergillus predominates during the rainy season. High altitude lung disease may also compound the problem, particularly in Kandahar, Afghanistan. Clinically, soldiers may present with new-onset asthma or fixed airway obstruction. Some have constrictive bronchiolitis and vascular remodeling on open lung biopsy - despite having normal spirometry and chest xrays and CT scans of the chest. Others have been found to have titanium and other metals in the lung (rare in nature). Still others have fulminant biopsy-proven sarcoidiosis. We found DNA probe-positive Mycobacterium Avium Complex in lung from a soldier who had pneumonia, while serving near stagnant water and camels and goats outside Abu Gharib. This review highlights potential exposures, clinical syndromes, and the Denver Working Group recommendations on post-deployment health.

Keywords: Aeroallergenaspergillus; Bronchiolitis; Burn pits; Mycobacterium avium complex.

Figures

Figure 1

Attachment from book Rogue Bee by Anhtony Szema, Creatspace 2010

Figure 2

Al Asad, Iraq Dust storm photo taken by U.S. Marine Corps Gunnery Sergeant Shannon Arledge 2005.

Figure 3

In the soldier with dyspnea who was in charge of the laundry in Balad, Iraq, open lung biopsy showed Nonspecific Interstitial Pneumonitis or NSIP (left). Areas of titanium overlapping with iron, indicating titanium and iron are bound together, indicating new-onset “Metal Lung.”

Figure 4

Summary of common exposures in Iraq (clockwise from left to right): blast overpressure, indoor aeroallergens such as aspergillus, Improvised Explosive Devices, sandstorms, outdoor aeroallergens, and burn pits.

Figure 5

Mean FEV1/FVC % is lower than that of never and current smokers in the National Health and Nutrition Education Survey (NHANES) database from the Centers for Disease Control as outlines in the article by Hansen in CHEST.

Figure 6

Mean FEV1/FVC percentage among soldiers with new-onset asthma is lower than that of healthy Caucasians, African-Americans, and Mexican-Americans in the NHANES database.

Figure 7

Air pollution levels in Balad, Iraq, where all new-onset asthmatics passed, were above Environmental Protection Agency limits.

Figure 8

Constrictive Bronchiolitis, Arteriopathy and Peribronchial Pigment Deposition. The photomicrographs show some of the pathological features seen in the 38 soldiers in whom constrictive bronchiolitis was diagnosed. The disorder was associated with subepithelial fibrosis (Panel A, arrow; Hematoxylin &Eosin), smooth-muscle hypertrophy (Panel B, arrow; hematoxylin and eosin), fibrosis between the epithelium and the muscle layer (Panel C, arrow; stained red with Masson’s trichrome), smooth-muscle hypertrophy (Panel D, black arrow) with marked intimal fibrosis and medial hypertrophy of the adjacent pulmonary artery (white arrow) and peribronchiolar pigment deposition (arrowhead; hematoxylin and eosin), and smooth-muscle hypertrophy (Panel E, arrow) with adjacent pigment deposition (arrowhead; hematoxylin and eosin). Panel F shows the field shown in Panel E with the pigment refringent under polarized light.