What Are They Smoking
At The Pentagon?
From Patricia Doyle, PhD

Smoke and Mirrors!
Pentegon Puffs Out Blame For Mystery Pneumonia Hitting US Troops In On 'CIGARETTE SMOKING'
I wonder what the Pentegon Epdemiologists have been smoking when they came up with this 'cause' for military respiratory illness cases? As I mentioned previously when the Military claimed they knew what was responsible for the illness and death of troops in Iraq, they haven't a clue.
Of course, cigarette smoking is detrimental to one's health but it's not the major culprit here. Depleted Uranium and other pollutants in the Iraqi environment are far more harmful than cigarette smoking. However, it has been suggested that the gummy nicotine in the troop's lungs would certainly be like glue for inhaled DU.
The military should look a lot farther then "cigarettes" as the cause of the current mystery respiratory outbreak. After all, troops have been smoking cigarettes for eons - especially during combat operations - but this is the first time I have heard of cigarette smoking named as the cause of pneumonia that progressed to ventilator intervention and deaths. Either the miltary is clueless... or they KNOW what is causing the illness but don't want to make the information public.
Patricia Doyle
A ProMED-mail post ProMED-mail is a program of the International Society for Infectious Diseases
[1] Date: Wed, 10 Sep 2003 17:13:24 +0100 From: George Robertson < Source: New York Times 10 Sep 2003 [edited] <
Smoking Tied to Pneumonia Cases in War Zones
The puzzling cluster of pneumonia cases among American troops in Iraq and other countries in the war region seems to be partly related to the fact that many had taken up smoking shortly before they became ill, Pentagon officials said 9 Sep 2003.
2 teams of military and civilian epidemiologists and environmental health specialists have been investigating a cluster of 19 cases of severe pneumonia, including 2 deaths, that occurred from 1 Mar through August 2003. No new cases have occurred since 20 Aug 2003, and the earlier patients have all been discharged from the hospital.
"We do not have an epidemic," and there is not an unusual number of pneumonia cases among troops in the war area, Dr. William Winkenwerder Jr., Assistant Secretary of Defense for Health Affairs, told reporters in a telephone conference call.
He said the military has investigated the cluster because of the particular severity of the pneumonia -- all patients needed assistance from mechanical ventilators to breathe. Most responded "fairly dramatically" within days after such therapy and antibiotics, said Col. Bob DeFraites, the Army's chief of preventive medicine.
The SARS coronavirus, adenovirus, parasites, and vaccinations against smallpox or anthrax have been ruled out. Though the specific cause of the outbreak has not been identified, "we have a somewhat improved understanding" of what the phenomenon is, Dr. Winkenwerder said.
The investigators found that 4 of the 19 patients had suffered bacterial pneumonia. Of the other 15 cases, 10, including the 2 men who died, had markedly increased numbers of a certain type of white blood cell known as an eosinophil. The eosinophil count was from 4 to 11 times higher than normal.
The investigators are leaning towards a noninfectious cause and are focusing on one finding "that has jumped out at us," that 9 of the 10 patients with high eosinophil counts reported that they had started smoking recently, Dr. DeFraites said.
Tobacco smoke is a prime suspect because it is known to damage lungs and increase their susceptibility to pneumonia. Also, at least one published paper has reported a similar link between smoking and severe pneumonia. A combination of stress, heat, dust, and other factors may have acted in concert with smoking to cause illness, Dr. DeFraites said.
Pentagon officials provided no information on what cigarette brand the sick individuals smoked but said such information could come from additional studies that are being planned.
13 of the patients became ill in Iraq. 3 became ill in Kuwait, and one each in Qatar, Uzbekistan, and Djibouti. There has been no evidence of person-to-person spread of the illness. Only 2 of the cases involved members of the same battalion, and the onset of their illness was 4 months apart.
[Byline: Lawrence K. Altman]
-- George A. Robertson, PhD ITT - Advanced Engineering and Sciences Alexandria, VA <
[A summary of the information as provided by American Forces Press Service can be found at < - Mod.LL]
****** [2] Date: Thu, 11 Sep 2003 From: ProMED-mail < Source: Morbid Mortal Weekly Rep 2003;52:857-59. [edited] <
Severe Acute Pneumonitis Among Deployed US Military Personnel - Southwest Asia, Mar-Aug 2003 ------------------------------------------------- During March-August 2003, a total of 19 US military personnel deployed in the Central Command (CENTCOM) area of responsibility had bilateral pneumonitis requiring intubation and mechanical ventilation [see figure at above website - Mod.LL]); 2 patients died. This report summarizes the results of the US Army's investigation of these cases and describes the ongoing investigation to determine the cause(s). Cases of rapidly progressive respiratory failure among former or current CENTCOM personnel should be reported to state health departments and to the Department of Defense (DoD).
Of the 19 patients (median age: 25 years; range: 19-47 years), 18 were men; 12 were full-time active duty personnel, and 7 were in the Reserve Component or National Guard (based in Arkansas, Illinois, Indiana, Kansas, Missouri, New Mexico, and North Dakota). 17 were in the Army, one was in the Navy, and one was in the Marine Corps; 11 were junior enlisted personnel, 7 were noncommissioned officers, and one was an officer. Military specialties included combat arms (8), engineering (3), transportation (2), signal corps (2), medical services (2), supply (one), and military police (one). Illness onset occurred a median of 81 days (range: 1-189 days) after arrival in the area of responsibility.
10 patients had evidence of elevated eosinophils in at least one of the following: peripheral blood (8), bronchoalveolar lavage fluid (3), pulmonary tissue (1), or pleural fluid (1). Among the 8 patients with peripheral eosinophilia, the maximum absolute number of eosinophils was 2000-6600 in microL of blood (normal: <600). The peripheral eosinophilia was detected a median of 6 days (range: 4-11 days) after illness onset.
An interim case definition has been established. A confirmed case of severe acute pneumonitis with elevated eosinophils is defined as an illness occurring in a current or former member of the US armed forces or a US government employee deployed to the CENTCOM area of responsibility who had 1) bilateral pneumonitis (i.e., radiographically confirmed pulmonary infiltrates) that required mechanical ventilation and that did not result from a complication of another medical condition and 2) elevated pulmonary eosinophils (identified histologically, in bronchoalveolar lavage fluid [5 percent] or in pleural fluid [5 percent]). A probable case is defined as an illness in a person deployed to the CENTCOM area of responsibility who had bilateral pneumonitis requiring mechanical ventilation and the presence of peripheral eosinophilia (600 microL blood absolute count). A suspect case is defined as an illness in a person deployed to the CENTCOM area of responsibility who had bilateral pneumonitis requiring mechanical ventilation only.
As of 8 Sep 2003, 4 cases were confirmed, 6 were probable, and 9 were suspect. 4 patients had laboratory evidence of infection with a microbial agent. _Streptococcus pneumoniae_ was isolated from sputum culture in one probable case. 3 patients with suspect cases showed evidence of infection (_S. pneumoniae_ based on urine antigen, _Coxiella burnettii_ based on serology, and _Acinetobacter baumannii_ from bronchoscopic culture). [ProMED previously posted a cluster of community-acquired _Acinetobacter_ infections in Iraq - Acinetobacter, drug resistant - Iraq: RFI 20030417.0934 - Mod.LL]
All patients were treated with broad-spectrum antibiotics, and 6 received corticosteroids, including 2 patients whose cases were confirmed and 3 whose cases were probable. The course of illness varied (median duration of intubation: 6 days; range: 2-35 days). For some patients, infiltrates and respiratory failure resolved rapidly (i.e., 2-3 days) with or without steroids, and other patients required longer periods of mechanical ventilation. All 17 surviving patients either have been placed on convalescent leave or have returned to duty.
When they became ill, 13 patients were in Iraq, and 6 were in other countries (Kuwait [3], Djibouti [1], Qatar [1], and Uzbekistan [1]). Other than 2 patients from the same unit with suspect cases and with onset of illness 4 months apart, no apparent geographic or unit-level clustering has been identified. Of the 19 patients, 15 (79 percent) smoked cigarettes or cigars, including the 10 patients whose cases were either confirmed or probable. 9 of these 10 patients had begun smoking tobacco after deployment, compared with none of the 9 patients whose cases were suspect. 2 recent-onset smokers reported smoking non-US-brand cigarettes. All troops in the CENTCOM area of responsibility have been exposed to heat, dust, and various amounts of environmental pollution (e.g., smoke).
The US Army is conducting a clinical and epidemiologic investigation to identify the cause(s) of this disease, including intensive testing of clinical material (i.e., blood, urine, bronchoalveolar lavage fluid, and acute and convalescent sera) to identify potential microbial pathogens and toxins. In addition, military personnel are interviewing patients systematically to identify any common exposures or practices. Environmental testing to identify potential toxins will be guided by clinical, diagnostic, and patient surveys. Initial data analysis suggests that medications, vaccines, and biologic weapons are not associated with the disease.
Reported by: Operation Iraqi Freedom Severe Acute Pneumonitis Epidemiology Group, U.S. Army Medical Command. National Center for Infectious Diseases; National Center for Environmental Health, CDC.
MMWR Editorial Note: The majority of cases of acute lower respiratory illness (LRI) among US military personnel in Southwest Asia have been comparable clinically and have occurred at a rate similar to those in other military populations and settings (1). In contrast, the rapidly progressive LRI cases described in this report were life-threatening and required intensive medical care, including mechanical ventilation with high-end expiratory pressures.
Although investigations are ongoing, preliminary findings suggest a subset of these cases are compatible with the diagnosis of acute eosinophilic pneumonia (AEP). AEP is an acute febrile illness without an identifiable infectious cause that is characterized by the rapid onset and progression of respiratory failure, diffuse bilateral infiltrates on chest radiographs, and elevated eosinophils in lung biopsy specimens or bronchoalveolar lavage fluid (2).
Cigarette smoking (particularly of recent onset) is a risk factor for AEP (3-7), and some affected persons have experienced acute respiratory distress when exposed to cigarette smoke in a laboratory setting (5,6). The finding that 9 of the 10 persons whose cases were severe and who had documented elevated eosinophils started smoking cigarettes after their deployment suggests the possibility of a toxin or allergen exposure; however, no single brand of cigarette or location of production has been implicated in this association. DoD has advised CENTCOM personnel that cigarette smoking, particularly the initiation of smoking, might be associated with the development of severe acute pneumonitis with elevated eosinophils.
In 1997, 2 US soldiers had rapidly progressive acute respiratory distress syndrome and elevated eosinophils shortly after returning from field training in the Mojave Desert in California (8). The occurrence of these cases in troops who were not deployed overseas suggests that exposures unique to Iraq (e.g., abandoned buildings, unexploded ordnance, and war-damaged vehicles or equipment) or to any of the countries in which the cases occurred (e.g., indigenous food, water, and materials) might not be necessary or sufficient for the development of this disease.
No US-based military personnel are known to have had severe acute pneumonitis with increased eosinophils during this period. However, the return of troops from Southwest Asia raises the possibility that US health-care providers might be the first to observe members of this population who experience otherwise unexplained acute respiratory failure.
Clinicians should elicit the travel histories of patients with rapidly progressive respiratory failure of unknown etiology and report cases among persons -- particularly military personnel -- who have returned recently from the CENTCOM area of responsibility to their state health department and to the U.S. Army Center for Health Promotion and Preventive Medicine, telephone 410-436-4655.
1. Gray GC, Callahan JD, Hawksworth AW, et al. Respiratory diseases among U.S. military personnel: countering emerging threats. Emerg Infect Dis 1999;3:379-85.
2. Allen JN, Pacht ER, Gadek JE, et al. Acute eosinophilic pneumonia as a reversible cause of noninfectious respiratory failure. N Engl J Med 1989;321:569-74.
3. Shiota Y, Kawai T, Matsumoto H, et al. Acute eosinophilic pneumonia following cigarette smoking. Intern Med 2000;39:830-3.
4. Shintani H, Fujimura M, Yasui M, et al. Acute eosinophilic pneumonia caused by cigarette smoking. Intern Med 2000;39:66-8.
5. Tanino Y, Yamaguchi E, Takaoka K, et al. Cytokines and Th2 cells in AEP of smoking. Allergy 2002;57:463-4.
6. Watanabe K, Fujimura M, Kasahara K, et al. Acute eosinophilic pneumonia following cigarette smoking: a case report including cigarette-smoking challenge test. Intern Med 2002;41:1016-20.
7. Nakajima M, Manabe T, Sasaki T, Niki Y, Matsushima T. Acute eosinophilic pneumonia caused by cigarette smoking. Intern Med 2000;39:1131-2.
8. Giacoppe GN, Degler DA. Rapidly evolving adult respiratory distress syndrome with eosinophilia of unknown cause in previously healthy active duty soldiers at an Army training center: report of two cases. Mil Med 1999;164:911-6.
-- ProMED-mail <
[This newly available CDC paper is the most detailed report regarding the clinical and microbiological aspects of the cases. It may well the case that recent onset of tobacco smoking may play a role in the cases. Data on smoking habits of totally unaffected personnel would be instructive. It is not clear whether rechallenge with cigarettes (if they contain the potential immunogen) would cause a relapse. One 1997 report from Japan suggested it might (1), but one later report from the same group reported that it did not (2).
1. Sasaki T, Nakajima M, Kawabata S, et al. Acute eosinophilic pneumonia induced by cigarette smoke [Japanese]. Nihon Kyobu Shikkan Gakkai Zasshi 1997;35:89-94.
2. Nakajima M, Yoshida K, Miyashita N, et al. Eosinophilia and cough induced by resumption of cigarette smoking in a beginning smoker recovering from acute respiratory failure [Japanese]. Nihon Kokyuki Gakkai Zasshi 1999;37:543-48. - Mod.LL]
Patricia A. Doyle, PhD Please visit my "Emerging Diseases" message board at: diseases
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