Acute eosinophilic pneumonia in the deployed military setting.

RATIONALE: Acute eosinophilic pneumonia (AEP) is a rare but important cause of severe respiratory failure most typically caused by cigarette smoking, but can also be caused by medications, illicit drugs, infections and environmental exposures. There is growing evidence that disease severity varies and not all patients require mechanical ventilation or even supplemental oxygen. OBJECTIVES: To compare patients with AEP treated at Landstuhl Regional Medical Center (LRMC) to those in other published series, and to provide recommendations regarding diagnosis and treatment of AEP. METHODS: A retrospective chart review was completed on forty-three cases of AEP which were identified from March 2003 through March 2010 at LRMC, Germany. RESULTS: Tobacco smoking was reported by 91% of our patients. Only 33% of patients in our series had a fever (temperature > 100.4 °F) at presentation. Peripheral eosinophilia (>5%) was present in 35% on initial CBC, but was seen in 72% of patients during their hospital course. Hypoxemia, as measured by PaO2/FiO2 ratio, seemed to be less severe in patients with higher levels of bronchoalveolar (BAL) eosinophilia percentage. CONCLUSIONS: Based on our experience and literature review, we recommend adjustments to the diagnostic criteria which may increase consideration of this etiology for acute respiratory illnesses as well as provide clinical clues we have found particularly helpful. Similar to recent reports of initial peripheral eosinophilia correlating with less severe presentation we found that higher BAL eosinophilia correlated with less severe hypoxemia.

Characteristics of HIV-infected U.S. Army soldiers linked in molecular transmission clusters, 2001-2012.

OBJECTIVE: Recent surveillance data suggests the United States (U.S.) Army HIV epidemic is concentrated among men who have sex with men. To identify potential targets for HIV prevention strategies, the relationship between demographic and clinical factors and membership within transmission clusters based on baseline pol sequences of HIV-infected Soldiers from 2001 through 2012 were analyzed. METHODS: We conducted a retrospective analysis of baseline partial pol sequences, demographic and clinical characteristics available for all Soldiers in active service and newly-diagnosed with HIV-1 infection from January 1, 2001 through December 31, 2012. HIV-1 subtype designations and transmission clusters were identified from phylogenetic analysis of sequences. Univariate and multivariate logistic regression models were used to evaluate and adjust for the association between characteristics and cluster membership. RESULTS: Among 518 of 995 HIV-infected Soldiers with available partial pol sequences, 29% were members of a transmission cluster. Assignment to a southern U.S. region at diagnosis and year of diagnosis were independently associated with cluster membership after adjustment for other significant characteristics (p<0.10) of age, race, year of diagnosis, region of duty assignment, sexually transmitted infections, last negative HIV test, antiretroviral therapy, and transmitted drug resistance. Subtyping of the pol fragment indicated HIV-1 subtype B infection predominated (94%) among HIV-infected Soldiers. CONCLUSION: These findings identify areas to explore as HIV prevention targets in the U.S. Army. An increased frequency of current force testing may be justified, especially among Soldiers assigned to duty in installations with high local HIV prevalence such as southern U.S. states.

Centralized HIV Program Oversight: An Investigation of a Case Series of New HIV Infections among US Army Soldiers, 2012 to 2013.

Centralized HIV program oversight and repeal of the Department of Defense policy "Don't Ask Don't Tell" permitted characterization of HIV transmission among soldiers assigned to a large US Army base continental United States from 2012 to 2013. An investigation of a greater than expected number of new HIV infections among soldiers was initiated to characterize transmission and identify opportunities to disrupt transmission and deliver services.All soldiers who were assigned to the base at the time of their first positive HIV test and who had their first positive HIV test in 2012 or in the first 6 months of 2013 and who had a clinical genotype available for analysis were eligible for inclusion in the investigation.All patients (n = 19) were men; most were black (52%) and less than 30 years old (64%). Fifteen of the 19 patients participated in in-depth interviews. Eighty percent were men who have sex with men who reported multiple sex partners having met through social and electronic networks. All were subtype B infections. Significant knowledge gaps and barriers to accessing testing and care in the military healthcare system were identified. Most (58%) belonged to transmission networks involving other soldiers.This investigation represents an important step forward in on-going efforts to develop a comprehensive understanding of transmission networks in the Army that can inform delivery of best practices combination prevention services. The Army is developing plans to directly engage individuals in key affected populations most at risk for HIV infection to identify and address unmet needs and expand delivery and uptake of prevention services. Further investigation is underway and will determine whether these findings are generalizable to the Army.

Brief Report: Sexual Risk Behaviors of HIV Seroconverters in the US Army, 2012-2014.

The United States (US) Army implemented a comprehensive HIV characterization program in 2012 following repeal of the Don't Ask, Don't Tell policy banning openly homosexual individuals from serving in the US military. Program staff administered a standardized case report form to soldiers newly diagnosed with HIV from 2012 to 2014 in compliance with new program requirements. The case report form documented sociodemographic, sexual, and other risk behavior information elicited from US Army regulation-mandated epidemiologic interviews at initial HIV notification. A majority of HIV-infected soldiers were male and of black/African American racial origin. In the HIV risk period, male soldiers commonly reported male-male sexual contact, civilian partners, online partner-seeking, unprotected anal sex, and expressed surprise at having a positive HIV result. Don't Ask, Don't Tell repeal allows for risk screening and reduction interventions targeting a newly identifiable risk category in the US Army. At-risk populations need to be identified and assessed for possible unmet health needs.

Confirmed malaria cases among active component U.S. Army personnel, January-September 2012.

Of 26 cases of malaria reported among active component U.S. Army personnel during January through September 2012, 16 were laboratory-confirmed according to electronic medical records. Medical records and responses on postdeployment health assessment questionnaires were used to assess demographic and clinical characteristics, adherence to malaria prevention measures, and compliance with prescriptions for chemoprophylaxis. All but two cases were confirmed by peripheral blood smears. Twelve cases were caused by Plasmodium vivax, one by P. falciparum, and three unspecified diagnoses were deemed likely to be due to P. vivax. Fourteen cases were associated with deployment to Afghanistan. Adherence to Army malaria prevention measures during deployment and compliance with post-deployment primaquine chemprophylaxis were poor. Prescribed doses of primaquine often varied from current clinical or Department of Defense policy guidelines. Continued education, training and reinforcement of malaria prevention by medical and preventive medicine personnel are indicated, as is blood smear confirmation of suspected malaria cases. Unit commanders and supervisors play a crucial role in ensuring soldiers' adherence to malaria prevention measures.

An investigation of bloodborne pathogen transmission due to multipatient sharing of insulin pens.

On January 30, 2009, nursing staff at a military hospital in Texas reported that single-patient use insulin pens were used on multiple patients. An investigation was initiated to determine if patient-to-patient bloodbome transmission occurred from the practice. Human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) testing was offered to patients hospitalized from August 2007 to January 2009 and prescribed insulin pen injections. Virus from HCV-infected patients' sera was sequenced and compared for relatedness. An anonymous survey was administered to nurses. Of 2,113 patients prescribed insulin pen injections, 1,501 (71%) underwent testing; 6 (0.4%) were HIV positive, 6 (0.4%) were hepatitis B surface antigen positive, and 56 (3.7%) had HCV antibody. No viral sequences from 10 of 28 patients with newly diagnosed and 12 of 28 patients with preexisting HCV infection were closely related. Of 54 nurses surveyed, 74% reported being trained on insulin pen use, but 24% believed nurses used insulin pens on more than one patient. We found no clear evidence of bloodborne pathogen transmission. Training of hospital staff on correct use of insulin pens should be prioritized and their practices evaluated. Insulin pens should be more clearly labeled for single-patient use.

PCR for rapid diagnosis of acute Q fever at a combat support hospital in Iraq.

Acute Q fever is occasionally seen in U.S. military service members deployed to Iraq. Diagnosis relies on serology, which is not available in the combat zone. Improved diagnostic modalities are needed. We performed a pilot study investigating whether Joint Biological Agent Identification and Diagnostic System (JBAIDS), a ruggedized, deployable polymerase chain reaction (PCR) platform, might be useful in the diagnosis of acute Q fever. Patients presenting to a Combat Support Hospital in Iraq with undifferentiated fever had blood drawn for Q fever PCR and these results were compared with serology. PCR was positive in 6 of 9 patients with acute Q fever by serology and negative in all 9 patients with negative serology. These results suggest that PCR using the JBAIDS platform could be of use in the diagnosis of Q fever in deployed settings. Further research into this modality is warranted.

Deaths attributed to suicide among enlisted U.S. Armed Forces recruits, 1980-2004.

OBJECTIVE: The purpose of this study was to describe the epidemiology of suicides among U.S. Air Force, Army, Marine Corps, and Navy recruits from 1980 through 2004. METHODS: Recruit suicides were identified through the Department of Defense Recruit Mortality Registry. We calculated crude, category-specific, and age-adjusted mortality rates as deaths per 100,000 recruit-years. RESULTS: There were 46 onsite suicides by gunshot (39%), hanging (35%), fall/jump (22%), and drug overdose (4%). An additional 20 recruits committed suicide from 1980 through 2004 after leaving the military training site. Methods included gunshot (70%), hanging (20%), fall/jump (5%), and poisoning (5%). Therefore, the overall recruit suicide rate was 6.9 (95% confidence interval = 5.4-8.8) deaths per 100,000 recruit-years. Only three (5%) suicides occurred among females resulting in a 3.5 times higher risk for males compared to females (95% confidence interval = 1.1-11.2). CONCLUSIONS: Suicide rates among military recruits were lower than those of comparably aged U.S. civilians. However, the occurrence of any suicide during basic military training emphasizes the importance of routine evaluation of the effectiveness of each military service's suicide prevention program as it applies to this population.

Causes of sudden death in young female military recruits.

This study sought to examine the incidence of sudden death in a large, multiethnic cohort of young women. Approximately 852,300 women entered basic military training from 1977 to 2001. During this period, there were 15 sudden deaths in female recruits (median age 19 years, 73% African-American), occurring at a median of 25 days after arrival for training. Of the sudden deaths, 13 (81%) were due to reasons that may have been cardiac in origin. Presumed arrhythmic sudden death in the setting of a structurally normal heart was seen in 8 recruits (53%), and anomalous coronary origins were found in 2 recruits (13%). The mortality rate was 11.4 deaths per 100,000 recruit-years (95% confidence interval 6.9 to 18.9). The rate was significantly higher for African-American female recruits (risk ratio 10.2, p <0.001). Sudden death with a structurally normal heart was the leading cause of death in female recruits during military training.

Sudden death associated with anomalous coronary origin and obstructive coronary disease in the young.

Sudden cardiac death in a young patient is a catastrophic occurrence. Anomalous coronary origin (ACO) is a significant cause of sudden cardiac death among individuals under the age of 35 years. We sought to define the premortem clinical and postmortem histopathologic findings in victims of sudden cardiac death resulting from either ACO or obstructive atherosclerotic coronary artery disease (CAD) among U.S. military recruits (ages 17-35 years). The autopsy records of all sudden cardiac deaths occurring among recruits during their basic military training period from 1977 through 2001 were reviewed. Twenty-one deaths were associated with ACO and 10 with CAD. Recruits with ACO were more likely to have prodromal symptoms of exertional syncope and/or chest pain (48% vs. 0%, P = 0.011). All sudden cardiac deaths resulting from ACO involved a left main coronary artery takeoff from the right coronary sinus with a course between the aorta and the right ventricular outflow tract and an otherwise normal distribution of the major epicardial coronary arteries. Myocardial fibrosis was seen equally in those with both CAD and ACO (30% vs. 20%, P = 0.66), but the finding of necrosis tended to be more common among recruits with CAD (50% vs. 15%, P = 0.08). In conclusion, review of autopsy data of sudden cardiac deaths among U.S. military recruits reveals myocardial fibrosis or necrosis occurred in 70% of cases with CAD and 35% of cases with ACO. Sudden cardiac deaths resulting from ACO were more likely to be associated with premortem exertional chest discomfort and/or syncope compared with deaths resulting from CAD.

Acute eosinophilic pneumonia among US Military personnel deployed in or near Iraq.

CONTEXT: Acute eosinophilic pneumonia (AEP) is a rare disease of unknown etiology characterized by respiratory failure, radiographic infiltrates, and eosinophilic infiltration of the lung. OBJECTIVES: To describe a case series of AEP, illustrate the clinical features of this syndrome, and report the results of an epidemiologic investigation. DESIGN, SETTING, AND PARTICIPANTS: Epidemiologic investigation of cases of AEP identified both retrospectively and prospectively from March 2003 through March 2004 among US military personnel deployed in or near Iraq. Survivors were offered a follow-up evaluation. MAIN OUTCOME MEASURE: Morbidity and mortality related to AEP. RESULTS: There were 18 cases of AEP identified among 183,000 military personnel deployed in or near Iraq during the study period, yielding an AEP incidence of 9.1 per 100,000 person-years (95% confidence interval, 4.3-13.3). The majority of patients (89%) were men and the median age was 22 (range, 19-47) years. All patients used tobacco, with 78% recently beginning to smoke. All but 1 reported significant exposure to fine airborne sand or dust. Known causes of pulmonary eosinophilia (eg, drug exposures or parasitic disease) were not identified. Epidemiologic investigation revealed no evidence of a common source exposure, temporal or geographic clustering, person-to-person transmission, or an association with recent vaccination. Six patients underwent bronchoalveolar lavage (median eosinophilia of 40.5%). All patients developed peripheral eosinophilia (range, 8%-42%). Mechanical ventilation was required in 67% for a median of 7 (range, 2-16) days. Two soldiers died; the remainder responded to corticosteroids and/or supportive care. Twelve individuals were reevaluated a median of 3 months after diagnosis. At that point, 3 patients reported mild dyspnea and 1 reported wheezing. All patients had finished treatment and had either normal or nearly normal spirometry results. None had recurrent eosinophilia. CONCLUSIONS: AEP occurred at an increased rate among this deployed military population and resulted in 2 deaths. Failure to consider AEP in the differential diagnosis of respiratory failure in military personnel can result in missing this syndrome and possibly death. The etiology of AEP remains unclear, but the association with new-onset smoking suggests a possible link.

Sudden death in young adults: a 25-year review of autopsies in military recruits.

BACKGROUND: Sudden death among military recruits is a rare but devastating occurrence. Because extensive medical data are available on this cross-sectional and diverse population, identification of the underlying causes of sudden death may promote health care policy to reduce the incidence of sudden death. OBJECTIVE: To determine the causes of nontraumatic sudden death among a cohort of military recruits. DESIGN: Retrospective cohort study using demographic and autopsy data from the Department of Defense Recruit Mortality Registry. SETTING: Basic military training. PATIENTS: All nontraumatic sudden deaths from a monitored 6.3 million men and women age 18 to 35 years. MEASUREMENTS: Descriptive analysis, crude mortality rates of causes of sudden death, and frequency of events as a function of cause of death. RESULTS: Of 126 nontraumatic sudden deaths (rate, 13.0/100,000 recruit-years), 108 (86%) were related to exercise. The most common cause of sudden death was an identifiable cardiac abnormality (64 of 126 recruits [51%]); however, a substantial number of deaths remained unexplained (44 of 126 recruits [35%]). The predominant structural cardiac abnormalities were coronary artery abnormalities (39 of 64 recruits [61%]), myocarditis (13 of 64 recruits [20%]), and hypertrophic cardiomyopathy (8 of 64 recruits [13%]). An anomalous coronary artery accounted for one third (21 of 64 recruits) of the cases in this cohort, and, in each, the left coronary artery arose from the right (anterior) sinus of Valsalva, coursing between the pulmonary artery and aorta. LIMITATIONS: This cohort underwent a preenlistment screening program that included history and physical examination; this may have altered outcomes. CONCLUSIONS: Cardiac abnormalities are the leading identifiable cause of sudden death among military recruits; however, more than one third of sudden deaths remain unexplained after detailed medical investigation.

Cardiopulmonary and mental health diagnoses surrounding the September 11 terrorist acts in a military population.

BACKGROUND: In addition to psychological disorders, emotional stress can trigger a chain of neurohumoral imbalances that can manifest as cardiopulmonary complaints. No studies were identified that used objective clinical data on complaints after the terrorist attacks of September 11, 2001. The purpose of this descriptive study was to identify all cardiopulmonary and psychological diagnoses among active duty personnel seeking care at a military treatment facility and/or its ancillary facilities before and after September 11, 2001. METHODS: The study population included 40,981 active duty military personnel between August 13, 2001 and October 9, 2001 (4 weeks before and 4 weeks after September 11, 2001). Demographic and diagnostic data were obtained from the Composite Health Care System for each visit during the study period. The outcomes of interest were psychological and cardiopulmonary diagnoses. RESULTS: There were 19,595 clinic visits before September 11, 2001 compared to 19,207 clinic visits in the 4 weeks after September 11. There was no increase in total psychological diagnoses in the postexposure period, compared with the preexposure period (risk ratio (RR), 0.97; 95% confidence interval (CI), 0.84-1.11). The only statistically significant finding was a decrease in diagnoses of psychoses (RR, 0.62; 95% confidence interval, 0.42-0.91). However, diagnoses of depressive disorders were increased in the postexposure period (RR, 1.61; 95% CI, 0.89-2.90; p = 0.11). Total cardiopulmonary diagnoses did not increase in the postexposure period, compared with the preexposure period (RR, 0.96; 95% CI, 0.91-1.02). CONCLUSIONS: This descriptive study failed to identify evidence that any changes in cardiopulmonary or mental health diagnoses were attributable to September 11 terrorist attacks. In the unfortunate event of another national tragedy, it is recommended that health care professionals administer a questionnaire to determine why patients are seeking care after the tragedy. These data could be linked to International Classification of Diseases data to determine the effects of the tragedy on the health of personnel and their utilization of health care services.

Traumatic deaths during U.S. Armed Forces basic training, 1977-2001.

BACKGROUND: A Recruit Mortality Registry, linked to the Department of Defense Medical Mortality Registry, was created to provide comprehensive medical surveillance data for deaths occurring during enlisted basic military training. METHODS: Recruit deaths from 1977 through 2001 were identified and confirmed through redundant sources. Complete demographic, circumstantial, and medical information was sought for each case and recorded on an abstraction form. Mortality rates per 100,000 recruit-years were calculated by using recruit accession data from the Defense Manpower Data Center. RESULTS: There were 276 recruit deaths from 1977 through 2001 and age-specific recruit mortality rates were less than half of same-age U.S. civilian mortality rates. Only 28% (77 of 276) of recruit deaths were classified as traumatic (suicide, unintentional injury, and homicide), in comparison to three quarters in both the overall active duty military population and the U.S. civilian population (ages 15-34 years). The age-adjusted traumatic death rates were highest in the Army (four times higher than the Navy and Air Force, and 80% higher than the Marine Corps). The majority (60%) of traumatic deaths was due to suicide, followed by unintentional injuries (35%), and homicide (5%). The overall age-adjusted traumatic mortality rate was more than triple for men compared with women in all military services (rate ratio=3.9; p=0.01). CONCLUSIONS: There was a lower proportion of traumatic deaths in recruits compared to the overall active duty military population and same-age U.S. civilian population. This finding could be attributed to close supervision, emphasis on safety, and lack of access to alcohol and motor vehicles during recruit training.

Nontraumatic deaths during U.S. Armed Forces basic training, 1977-2001.

BACKGROUND: A Recruit Mortality Registry, linked to the Department of Defense Medical Mortality Registry, was created to provide comprehensive medical surveillance data for deaths occurring during enlisted basic military training. METHODS: Recruit deaths from 1977 through 2001 were identified and confirmed through redundant sources. Complete demographic, circumstantial, and medical information was sought for each case and recorded on an abstraction form. Mortality rates per 100,000 recruit-years were calculated by using recruit accession data from the Defense Manpower Data Center. RESULTS: There were 276 recruit deaths from 1977 through 2001 and age-specific recruit mortality rates were less than half of same-age U.S. civilian mortality rates. The majority (72%) of recruit deaths were classified as nontraumatic and 70% of these deaths (139 of 199) were related to exercise. Of the exercise-related deaths, 59 (42%) were cardiac deaths, and heat stress was a primary or contributory cause in at least 46 (33%). Infectious agents accounted for only 49 (25%) of the nontraumatic deaths. Nontraumatic death rates increased with age (rate ratio is 2.5 for 25+ v <25 years; p<0.001). The age- and gender-adjusted nontraumatic death rates were 2.6 times higher for African American than non-African American recruits (p<0.001). CONCLUSIONS: Although recruit mortality rates are lower than the same-age U.S. civilian population, preventive measures focused on reducing heat stress during exercise might be effective in decreasing the high proportion of exercise-related death. The availability of 25 years of comprehensive recruit mortality data will permit the ongoing evaluation of cause-of-death trends, effectiveness of preventive measures, and identification of emerging threats during basic military training.