Downrange Hazard?

Doctors see resurgence of rare type of pneumonia among some deployed troops

By STEVE MRAZ | STARS AND STRIPES Published: October 2, 2008

LANDSTUHL, Germany — Military doctors are seeing a resurgence of a rare and sometimes fatal type of pneumonia that is striking young troops who started smoking while deployed downrange.

In the past five months, six U.S. servicemembers serving in Central Command’s area of responsibility have been diagnosed with acute eosinophilic pneumonia, or AEP. While the exact cause of the illness is unknown, 27 of the 36 troops who have contracted AEP since March 2003 had recently picked up the habit, according to a July 2008 information paper from the Army’s Center for Health Promotion and Preventive Medicine.

Also, three-fourths of those troops came down with the illness while serving in Iraq. Other cases have originated with U.S. troops in Afghanistan, Djibouti, Kuwait, Qatar and Uzbekistan.

Two troops have died as a result of the disease.

On average, the AEP patients are around 22 years old, said Air Force Maj. (Dr.) Patrick Allan, a critical care pulmonary physician at Landstuhl Regional Medical Center.

"We do not know what the true underlying cause is," he said. "We only, epidemiologically, can say that it seems to be associated with new or increasing quantities of smoking and exposure to fine sand or dust from the local environment."

An additional three cases of AEP were reported by troops who increased the quantity of smoking while deployed, and two more reported infrequent use of cigarettes or cigarillos, according to the information paper.

Acute eosinophilic pneumonia is noninfectious, creates an inflammatory condition of the lungs and is associated with smoking, said Army Lt. Col. (Dr.) Eric Shuping, deputy commander of the Center for Health Promotion and Preventive Medicine-Europe.

AEP strikes hard and fast, doctors said. Within two weeks to two months of picking up smoking, people can begin showing symptoms.

In one to four days, patients may notice shortness of breath, a dry cough, chest pain and non-specific abdominal pain. Within 24 hours after going to a clinic, patients typically require supplemental oxygen or have to be put on a breathing machine, Allan said.

"We think that nicotine or products within the cigarette smoke alter the immune response that someone may have to other particles within the environment," he said. "The altered immune response may heighten their lungs’ inflammatory pattern such that they come out with this acute eosinophilic pneumonia, but that’s all hypothesis."

All the conclusive diagnoses for AEP have been made at Landstuhl, but in one case, doctors downrange had a suspicion the patient had AEP because he had just started smoking, Allan said.

In addition to the two servicemembers who died from complications of AEP, there have been others who were near death before recovering, doctors said. Landstuhl sent its specialty lung team downrange to treat three troops with AEP. The patients were so bad doctors had them on highly technical breathing machines to keep them alive.

In February 2007, a medical alert on AEP was issued in Iraq and signed by then-Lt. Gen. Ray Odierno, warning troops about the illness’ association with smoking. But because AEP is so rare, there are no good studies suggesting the military has a disproportionate number of cases compared to the U.S. civilian population, Allan said.

Now, young patients arriving at Landstuhl’s intensive care unit with pneumonia-like symptoms will immediately have their lungs examined for AEP, Allan said. Whereas "standard" pneumonia is usually treated with powerful antibiotics, AEP is treated with steroids that suppress the body’s immune system.

"By suppressing the eosinophils — a particular cell we believe is responsible for this condition — it causes the disease to melt away within a few days, and most do very well with it," Allan said.

Allan said there’s no good explanation as to what is causing the current resurgence of AEP.

"With each deployment cycle, there’s going to be a certain percentage of people who start smoking again to deal with the stress and the strain of just what they’re doing," he said. "I don’t have any data to suggest whether or not the incidence of new smoking is increasing or not, but it was just interesting that we saw so many cases."

Want to lessen your chances of contracting AEP? Stop smoking.

"This is yet another reason to not smoke," Shuping said. "…Don’t start. Don’t get addicted and cause yourself a problem down the road."

Unique mobile Landstuhl medical team brings expertise downrange

It’s like the Delta Force of military medicine.

Landstuhl Regional Medical Center’s Acute Lung Rescue Team travels downrange to treat and transport the most severely wounded and ill troops, who would otherwise be unable to be put on a medical evacuation flight.

The team’s expertise and specialized equipment, including advanced breathing machines and a device not approved by the U.S. Food and Drug Administration, set it apart from the military’s standard aeromedical evacuation and Critical Care Air Transport Teams. Only an extremely small percentage of wounded require the Landstuhl team’s services, but of the 19 times it has been called upon, 10 calls have come in the last year, said Air Force Lt. Col. (Dr.) Raymond Fang, a Landstuhl trauma surgeon.

Established in November 2005 by husband and wife Air Force Col. Warren Dorlac and Lt. Col. Gina Dorlac, the "ALRT team" (pronounced "alert") is one of a kind in the military and doesn’t have an official designation. Its personnel are doctors, nurses and specialists who generally work full-time in Landstuhl’s intensive care unit.

The Dorlacs, former Landstuhl doctors, are considered "the mom and dad" of the lung team, Fang said. Fang and Air Force Maj. (Dr.) Patrick Allan, a critical care pulmonary physician at Landstuhl, are the ALRT team leaders.

The Landstuhl team came about because doctors estimated there were a handful of wounded troops each year who could not be evacuated because of their grave conditions, Fang said.

"These 10 or 12 patients a year have to stay in Balad, Baghdad, Bagram, consume tremendous resources because they’re sick and they’re very labor extensive," Fang said. "And they just stay there until they get better — then they could be moved — or they die, which is not what we want."

When the Landstuhl team travels, it brings a surgeon, a pulmonary critical care doctor, one or two nurses and one or two respiratory therapists.

"You’re not sitting there on alert, waiting to go," Fang said. "You’re occupied in your job and then you get the call. You got to prepare. You got to fly down there. You got to stabilize the patient and then fly back. It is typically a 24-hour, constantly awake mission."

The Landstuhl team has been called 19 times, with 17 patients coming from Iraq and two from Afghanistan. Most suffered trauma wounds, but three were treated for eosinophilic pneumonia (see related story).

Because eight of the missions were canceled due to improvement in the patient’s health, or deaths prior to take off, the team has gone downrange 11 times. One patient died with the team at his bedside, but the 10 patients evacuated by the team have a 100 percent, seven-day survival rate.

"At least all these patients, we get them back to the States and back to their families, which is part of our goal — to get them back home as best as we can," Fang said.

— Steve Mraz

Sgt. Timothy Butler, a 2nd Brigade Combat Team soldier from Baumholder, Germany, takes a smoke break during a May 25, 2008, patrol in the town of Nasif, Iraq. Doctors at Landstuhl Regional Medical Center say they have seen a resurgence in acute eosinophilic pneumonia, a rare illness that medical officials believe might be caused by troops who began smoking while deployed downrange.

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