Deployment-Related Lung Disorders

The patient’s lung biopsy demonstrated constrictive changes in bronchioles, hyperinflation, and multiple chemodectomas in all 3 lobes of the right lung (Figures 2 and 3). Three pulmonary pathologists reviewed the biopsy and confirmed findings of constrictive bronchiolitis. Serologies for connective tissue disease were negative, indicating no autoimmune cause of bronchiolitis.

As no specific etiology was identified, the patient was referred for a second opinion with a pulmonologist with expertise in interstitial lung disease. Finding no evidence of post- infectious or autoimmune bronchiolitis, the patient’s diagnosis of constrictive bronchiolitis was deemed to be idiopathic. A number of years later, following publication of a case series of 38 OEF/OIF deployers with biopsy-proven constrictive bronchiolitis, the patient was referred for consultation to an occupational lung disease clinic.²⁴ He subsequently was diagnosed with deployment-related lung disease, as his constrictive bronchiolitis was thought to be related to exposures encountered during his OEF/OIF deployments from 2003 to 2005.

The patient was monitored with spirometry over the next few months. After observing a 10% decline in forced expiratory volume in 1 second (FEV₁) over 9 months despite stable lung volumes and diffusion capacity, the patient was started on macrolide therapy with erythromycin 500 mg daily. He was switched to azithromycin 250 mg daily due to gastrointestinal AEs of nausea and diarrhea while taking erythromycin. He continued use of an inhaled corticosteroid (ICS), as well as bronchodilator therapy with albuterol and formoterol and had stable dyspnea.

The patient was treated briefly with prednisone 40 mg, but he discontinued this medication after 5 days due to worsening anxiety and PTSD symptoms. Azithromycin therapy was discontinued after 4 years, because no significant improvement was noted in the patient’s lung function. Spirometry, lung volumes, and diffusion testing were unchanged for 2 years following discontinuation of azithromycin and continuing therapy with an ICS, long-acting beta-agonist, and albuterol. The patient has stable dyspnea on exertion but exercises regularly and recently was able to complete a marathon.

Case Study 2

A 43-year-old female ex-smoker presented to a VA chest clinic for evaluation of cough that started during a 2003 deployment to Iraq as well as dyspnea on exertion and chest tightness that had been present since her 2010 to 2011 deployment to Afghanistan. The patient had no history of asthma or other chronic respiratory disease during childhood.

She enlisted in the U.S. Navy in 1987 and later served as a medic while in the Navy Reserves. When she joined the U.S. Navy, she easily passed a 1.5-mile physical fitness readiness test run-time requirement with an 8.5-minute run time. She had no respiratory symptoms and ran in several marathons until her first SWA deployment in 2003.

In April 2003, she was deployed for 3 months to work as a combat medic near the Kuwait and Iraq border. She had frequent exposure to desert dust and recalled 5 sandstorms that appeared like a “wall of sand” coming toward the base. A few weeks into this deployment, the patient developed a nonproductive cough that persisted after returning to the U.S. She stopped smoking for a few months after returning home but continued to have a nonproductive cough. She did not seek further medical attention, because she had no exercise-limiting symptoms.

The patient joined the Army National Guard in 2006 and was activated in 2009 to deploy to Afghanistan from January 2010 through January 2011. She was stationed at Bagram Airbase for the entire deployment and worked as a military police officer in the prison. She had exposure to sandstorms and burn pit combustion products. The prison was about 2 miles downwind from a large burn pit.

In October 2010, she quit smoking again because of new-onset chest tightness and dyspnea on exertion. However, her symptoms did not abate, and she noted increased chest tightness and difficulty catching her breath when running near the burn pit. While she tried to avoid the burn pit, she participated in competitive races and a 10-mile run along paths that were near the burn pit.

After returning from deployment, the patient presented to her VA PCP for evaluation of persistent nonproductive cough, chest tightness, and dyspnea on exertion. She was not taking any respiratory or allergy medications at the time of evaluation. Initial chest X-ray and spirometry were normal, and she was referred to the chest clinic for consultation. At the time of pulmonary consultation, the patient had a total smoking history of 15 pack-years but had now abstained from smoking for about 2 years. She reported residential exposure to pet birds for > 20 years. High-resolution chest imaging and full PFT with lung volumes and diffusion capacity were performed to evaluate for hypersensitivity pneumonitis.