Troops' Pneumonia Outbreak Spurs Medical Hunt

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> washingtonpost.com

>

> Troops' Pneumonia Outbreak Spurs Medical Hunt

>

> By David Brown

> Washington Post Staff Writer

> Friday, September 12, 2003; Page A01

>

> Lt. Col. Janice M. Rusnak, recently arrived at the U.S. military hospital

> in Landstuhl, Germany, for a tour as infectious-diseases specialist,

walked

> into the third-floor intensive care unit. She didn't know the name of the

> patient she wanted to see. But she had what she considered a fairly good

> description.

>

> Can you point me to the soldier from Iraq who's on a ventilator? she asked

> a nurse. The one with acute respiratory distress syndrome.

>

> Which one? the nurse answered. We have three.

>

> Three cases in one place -- pretty strange, the 50-year-old Rusnak

> remembers thinking.

>

> Rusnak's observation that morning in late July was the opening chapter of

a

> medical whodunit -- the end of which still hasn't been written. Although

it

> has identified a surprising suspect, the military is still in the midst of

> a full-scale investigation to trace the source of a rare, and occasionally

> fatal, illness.

>

> What's clear so far is this: Since early March, about 100 soldiers

deployed

> to the Persian Gulf region and Central Asia have contracted pneumonia.

> About 30 have been ill enough to be sent to hospitals in Europe or the

> United States. In medical slang, 19 " crashed " within hours of getting

sick,

> not responding to antibiotics and requiring mechanical ventilators to

> breathe for them. Two have died.

>

> On the day she walked into the Landstuhl hospital, Rusnak was looking for

a

> patient about whom she had been told several days earlier in an e-mail

from

> doctors at the Army's 28th Combat Support Hospital in Iraq. They had a

> soldier with severe pneumonia whom they were thinking of evacuating to

> Germany. They were worried, and a little spooked. They had recently had a

> similar patient -- a 24-year-old sergeant with pneumonia who also needed a

> ventilator. He had gone into cardiac arrest and died while being prepared

> for a flight out.

>

> There's a saying in medicine that an " outbreak " is when you see one more

> case of a disease than you expect. Here were four young soldiers from Iraq

> sick enough with pneumonia to need machines to breathe for them, and one

> had died. This was not something Rusnak could easily pass by.

>

> And she didn't.

>

> Before the day was over, she and colleagues at Landstuhl notified Army

> epidemiologists in the United States that they might be looking at some

> sort of outbreak. What or how extensive it was, they weren't sure.

>

> Nothing obviously links the cases, the severe ones in particular. There is

> no evidence the illness is passed person to person. The 19 people -- 18

men

> and one woman -- were stationed across 2,600 miles, from Djibouti in the

> Horn of Africa to Uzbekistan in Central Asia, with most in Iraq. They had

a

> variety of military occupations. Only two were in the same unit, and they

> became ill six months apart.

>

> Overall, the incidence of pneumonia in deployed troops has not been wildly

> out of line with what is expected. It's the number of severe cases that's

> unusual -- that and the fact that 10 of them showed proliferation of

> uncommon immune system cells called eosinophils.

>

> Whatever the disease may be, it is clearly rare. It may even be new. The

> military's interest, however, isn't academic. It wants to learn what's

> going on so it can prevent future cases.

>

> The investigators are working in the long shadow of Gulf War syndrome, a

> grab bag of illnesses and physical complaints that emerged after the 1991

> war against Iraq. The Pentagon was accused of not paying enough attention

> to that problem, and doesn't want a repeat of that experience.

>

> Although the pneumonia outbreak and Gulf War syndrome differ in nearly

> every important characteristic, the Army is going after this one

> aggressively, deploying investigative teams, searching old records for

> similar cases and consulting civilian experts from the start.

>

> " Whether that reflects some hypervigilance -- I would say yes, it probably

> does. I would say I think we're much more sensitive to it because of the

> Gulf War experience, " said Col. Robert F. DeFraites, an epidemiologist and

> senior preventive medicine officer in the Army surgeon general's office.

>

> In many ways, it is a classic investigation of a rare medical event.

Unlike

> outbreaks of diarrhea and bronchitis, where there's an unmistakable spike

> in cases and the issue is what's causing them, outbreaks of rare

conditions

> begin with a more basic question. Is anything really happening here? Is

> there a new signal coming out of the usual background noise?

>

> Janice Rusnak thought she did hear a new signal. On the other side of the

> Atlantic, at the Army's Center for Health Promotion and Preventive

Medicine

> at Aberdeen Proving Ground outside Baltimore, Col. Bruno P. Petruccelli

> thought he heard one, too.

>

> " On one day, sitting here in my office, two things happened, " Petruccelli

> recalled recently.

>

> First, he received a copy of several e-mails Rusnak had sent from Germany

> to colleagues at the Army's infectious disease research center at Fort

> Detrick in Frederick. She described the rapid downhill course of several

> pneumonia cases she had seen. Electronically clipped to one message was a

> dramatically abnormal chest X-ray of a young soldier, the lungs nearly

> " whited out " with fluid, a condition often presaging death.

>

> Then came another e-mail message, this one from a woman in Kuwait working

> for the Army team that samples soil, air and water at encampment sites.

She

> had heard that the local military hospital had seen an unusual number of

> pneumonia cases. She even gave a number -- 17. The subject line of the

> message was " mysterious disease. "

>

> Shortly after he had read both messages, Petruccelli got a call from the

> doctor at Fort Detrick who had forwarded Rusnak's e-mails. He wanted to

> talk about them.

>

> " You couldn't have done it better in Hollywood. It all kind of blows in on

> one day, " Petruccelli recalled.

>

> The military has a long history of making discoveries in epidemiology and

> medicine. Its closely observed population of mostly young healthy people

is

> one in which the odd cases are likely to be noticed -- if your eyes are

> open to them. Already, doctors in the Iraq theater had noticed a number of

> infections in both American and Iraqi casualties caused by acinetobacter,

a

> relatively rare microbe found in soil. The pneumonias were another blip

> worthy of attention.

>

> Over the next two weeks, Rusnak and a military epidemiologist in Landstuhl

> tabulated cases of soldiers with pneumonia who had been sick enough to be

> flown out for treatment. They came up with 15 -- possibly an incomplete

> count, they thought -- and described them to Petruccelli and DeFraites in

a

> conference call on July 3.

>

> That afternoon, those two physicians held another conference call with

> stateside military doctors, one of whom suggested patching in Stephen M.

> Ostroff, an infectious-diseases expert at CDC and head of a committee of

> civilian advisers called the Armed Forces Epidemiological Board.

>

> " I remember telling them that in my experience, when healthy young adults

> develop a typical bacterial pneumonia, if they get a whiff of antibiotics

> they tend to turn around fairly quickly. It's unusual for people this age

> to deteriorate, " Ostroff recalls. " I strongly conveyed to them that this

> needed to be looked into, without question. "

>

> There were hints these strange cases might not be infections at all. Many

> of the sickest patients had deteriorated with a speed rarely seen in

> bacterial or viral pneumonias. The soldier for whom Rusnak went looking in

> the Landstuhl ICU was a good example.

>

> A soldier in his early twenties, he played volleyball the afternoon he got

> sick and after dinner was watching a movie when he suddenly became so

> breathless he thought he might pass out. The only other thing unusual that

> evening was a slight nosebleed. By the time he arrived by helicopter at

the

> 28th Combat Support Hospital near Baghdad, he had a 102-degree fever and

> was struggling to breathe. Within six hours of his first symptom, he was

on

> a ventilator.

>

> A case from Uzbekistan in April was similar: a young soldier who felt

well,

> then had 12 hours of mild chest tightness and shortness of breath before

he

> needed a machine to keep him alive.

>

> This picture is more typical of an out-of-control immune system reaction

> than an infection.

>

> On July 12, a second soldier died of multi-organ failure in Landstuhl. He

> had had a day of chest pain and breathlessness before being put on a

> ventilator on June 30.

>

> On July 17, the Army surgeon general launched an investigation.

>

> Although the count of about 100 cases of pneumonia since March 1 through

> mid-August turns out to be about what one might expect, what was unusual

> were features of some -- but not all -- of the severe cases.

>

> Of the original 19, four had evidence of bacterial infection. There was no

> evidence of other infectious respiratory diseases -- no severe acute

> respiratory syndrome, influenza, Legionnaire's disease, hantavirus,

> mycoplasma or fungal infections. Even more peculiar was what laboratory

> tests did show -- large numbers of the usually rare eosinophil cells in

the

> blood or lungs -- and sometimes both -- of 10 patients.

>

> Occasionally, exposure to chemicals or specific drugs can cause such cells

> to proliferate. When large numbers turn up in the blood -- a condition

> called eosinophilia -- in someone taking many medicines, it is usually

> chalked up as a drug reaction.

>

> There didn't appear to be any drug that had been taken by the 10 patients,

> but they did have one thing in common. All were smokers, and nine,

> including one who died, had started or resumed smoking during the

deployment.

>

> One of the nine was Lt. Cmdr. Glen Todd. The 47-year-old Navy

> nurse-anesthetist was working in a hospital in Djibouti when he woke up in

> a breathless sweat the night of Aug. 6. His condition worsened rapidly,

and

> he was evacuated to Landstuhl, where he was put on a ventilator Aug. 8.

>

is the oldest of the 19 patients who became seriously ill. He had

> smoked for several years in his twenties, but quit. In May he started

> again, eventually getting up to a half-pack of cigarettes a day and two

> cigars at night.

>

> " Why does anybody smoke or why does somebody drink a beer once in a

while? "

> he asked rhetorically in a telephone interview from his home in Great

> Lakes, Ill., where he is recuperating. " I think I started smoking over

> there mostly as a social thing. "

>

> Like many of the patients who needed ventilators, he turned around quickly

> and was off the machine in a few days, with no apparent lasting damage to

> his health.

>

> Smoking predisposes a person to pneumonia, and of the entire group of 19

> people on ventilators, 15 smoked. Nevertheless, the eosinophilia in new

> smokers seemed more than just a coincidence to Maj. Andrew Shorr, a lung

> specialist in Landstuhl. He found 12 intriguing papers published by

> Japanese physicians in the past six years. They reported cases of the rare

> disease, most of them in teenagers who had recently started smoking. All

> recovered quickly, sometimes with the help of steroids, which decrease

> inflammation. The researchers had re-exposed several to cigarette smoke to

> see if the eosinophilia returned, and it did.

>

> There was also a 1999 paper published by two Army doctors in the journal

> Military Medicine who reported two cases of severe pneumonia with

> eosinophilia in soldiers at Fort Irwin in Southern California. Both were

> smokers.

>

> Speaking from a Baghdad rooftop on a satellite telephone recently, Col.

> Bonnie L. Smoak, an Army physician leading the investigation in Iraq, said

> an epidemiologist there is surveying a sample of deployed soldiers to see

> how many recently began smoking.

>

> As to the ultimate explanation of the dangerous pneumonias, there is no

> shortage of theories.

>

> Although the investigators are still searching for and reviewing the

> records of all pneumonia cases, at least some of the 19 severe cases are

> sporadic, garden-variety cases caused by infection. But the patients with

> eosinophilia are probably a subgroup of their own.

>

> If they were all smokers, what else might they share? Was there a " second

> hit " they all got that hasn't yet been identified? Was there some common

> environmental exposure? Did it have something to do with the desert? Was

> there a genetic predisposition that made them vulnerable?

>

> Is it also possible that after a century in which hundreds of millions of

> people started smoking that a brand-new disease caused by the habit could

> turn up in 2003?

>

> " I am skeptical about that, " DeFraites said recently. " The big question to

> me is -- why here and why now? "

>

> The last case occurred Aug. 19. The Army isn't convinced it's the last.

The

> search for the culprit is narrowing, but it's not over.

>

>

> http://www.washingtonpost.com/wp-dyn/articles/A62963-2003Sep11.html

>