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Inhalational Constrictive Bronchiolitis: The Evolution of our Understanding of this Disease

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Abstract

The case definition of inhalational constrictive bronchiolitis (CB) has changed over the generations. We identify changes in the description of this illness over time associated with different exposures and present the natural history of CB in a case attributed to military burn pit exposure. The initial descriptions of this disease began with nitric acid spills and silage exposures. In these events, there was an acute exposure, typically a short-term resolution of the adverse respiratory events, and then a progression, leading to disability or a respiratory death. The life-saving role of corticosteroid therapy in this situation was recognized. War gas exposures of World War I and then Saddam Hussein’s use of sulfur mustard gas in the Iran-Iraq War followed. More recently the findings associated with diacetyl exposure in commercial popcorn workers remained consistent with previously described presentations, but then the clinical presentation in troops returning from deployment to Southwest Asia was very different, yet with the same histologic findings. We recognize unreconciled disparities in the clinical, physiologic, and imaging presentation in those with inhalational bronchiolitis and acknowledge this as perhaps one of the difficult diagnoses in respiratory medicine.

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References

  1. Figueiredo S, Morais A, Magalhaes A et al (2009) Occupational Constrictive Bronchiolitis with normal physical, functional and image changes. Rev Port Pneumol XV(4):729–732

    Article  Google Scholar 

  2. Spain BA, Cummings O, Garcia JGN (1995) Bronchiolitis obliterans in an animal feed worker. Am J Ind Med 28:437–443

    Article  CAS  PubMed  Google Scholar 

  3. Kraft M, Mortenson RL, Colby TV et al (1993) Cryptogenic constrictive bronchiolitis, a clinicopathologic study. Am Rev Respir Dis 148(4 Pt 1):1093–1101

    Article  CAS  PubMed  Google Scholar 

  4. King TE Jr (2003) Miscellaneous causes of bronchiolitis: inhalational, infectious, drug-induced, and idiopathic. Semin Respir Crit Care Med 24:567–576

    Article  PubMed  Google Scholar 

  5. Cummings KJ, Kreiss K (2015) Occupational and environmental bronchiolar disorders. Semin Respir Crit Care Med 36:366–378

    Article  PubMed  PubMed Central  Google Scholar 

  6. Krefft SD, Cool CD, Rose CS (2018) The emerging spectrum of exposure-related bronchiolitis. Curr Opin Allergy Clin Immunol 18:87–95

    Article  PubMed  Google Scholar 

  7. Wood FC (1912) Poisoning by nitric acid fumes. Arch Int Med 10:478–504

    Article  Google Scholar 

  8. Hayhurst ER, Scott E (1914) Four cases of sudden death in a silo. JAMA 63:1570–1572

    Article  CAS  Google Scholar 

  9. Lowry T, Schuman LM (1956) “Silo-filler’s disease”—a syndrome caused by nitrogen dioxide. JAMA 162:153–160

    Article  CAS  Google Scholar 

  10. Horvath EP, doPico GA, Barbee RA et al (1978) Nitrogen-dioxide-induced pulmonary disease. Five new cases and a review of the literature. JOEM 20:103–110

    CAS  Google Scholar 

  11. Zwemer FL Jr, Pratt DS, May JJ (1992) Silo filler’s disease in New York state. Am Rev Respir Dis 146:650–653

    Article  PubMed  Google Scholar 

  12. Amaza IP, Kreidy MP (2019) Silo-Filler’s Disease: One health system’s experience and an update of the literature. J Agromed 16:1–6

    Google Scholar 

  13. Winternitz MC (1920) Collected studies on the pathology of war gas poisoning from the Department of Pathology and Bacteriology, Medical Science Section, Chemical Warfare Service under the direction of M.C. Winternitz, Major, M.C., U.S.A. Yale University Press, New Haven

    Google Scholar 

  14. Easton DF, Peto J, Doll R (1988) Cancers of the respiratory tract in mustard gas workers. Br J Ind Med 45:652–659

    CAS  PubMed  PubMed Central  Google Scholar 

  15. Mukaida K, Hattori N, Iwamoto H et al (2017) Mustard gas exposure and mortality among retired workers at a poisonous gas factory in Japan: a 57-year follow-up study. Occup Environ Med 74:321–327

    Article  PubMed  Google Scholar 

  16. Nokhodian Z, ZareFarashbandi F, Shoaei P (2015) Mustard gas exposure in Iran-Iraq war—a scientometric study. J Educ Health Promot 4:56

    Article  PubMed  PubMed Central  Google Scholar 

  17. DeLuca MA, Chai PR, Goralnick E et al (2020) Five decades of global chemical terror attacks: data analysis to inform training and preparedness. Disaster Med Public Health Prep. https://doi.org/10.1017/dmp.2020.176

    Article  PubMed  PubMed Central  Google Scholar 

  18. Keshmiri M (1989) Pulmonary cause of death from chemical warfare agents: the Halbache experience. Iran J Med Sci 14(2):10–19

    Google Scholar 

  19. Kehe K, Thiermann H, Balswuweit F et al (2009) Acute effects of sulfur mustard injury—Munich experiences. Toxicology 263:3–8

    Article  CAS  PubMed  Google Scholar 

  20. Balali-Mood M, Hefazi M (2006) Comparison of early and late toxic effects of sulfur mustard in Iranian veterans. Basic Clin Pharm Toc 99:272–283

    Google Scholar 

  21. Ghanei M, Mokhtari M, Mohammad MM et al (2004) Bronchiolitis obliterans following exposure to sulfur mustard: chest high resolution computed tomography. Eur J Radiol 52:164–169

    Article  PubMed  Google Scholar 

  22. Bakhtavar K, Sedighi N, Moradi Z (2008) Inspiratory and expiratory high-resolution computed tomography (HRCT) in patients with chemical warfare agent exposure. Inhal Tox 20:507–511

    Article  CAS  Google Scholar 

  23. Ghanei M, Harandi AA, Tazelaar H (2012) Isolated bronchiolitis obliterans: high incidence and diagnosis following terrorist attacks. Inhal Toxicol 24(5):340–341

    Article  CAS  PubMed  Google Scholar 

  24. Borak J, Sidell FR (1992) Agents of chemical warfare: sulfur mustard. Ann Emerg Med 21:303–308

    Article  CAS  PubMed  Google Scholar 

  25. Rowell M, Kehe K, Balszuweit F et al (2009) The chronic effects of sulfur mustard exposure. Toxicology 263:9–11

    Article  CAS  PubMed  Google Scholar 

  26. Emad A, Rezaian GR (1997) The diversity of the effects of sulfur mustard gas inhalation on respiratory system 10 years after a single, heavy exposure: analysis of 197 cases. Chest 112:734–738

    Article  CAS  PubMed  Google Scholar 

  27. Konichezky S, Schattner A, Ezri T et al (1993) Thionyl-chloride-induced lung injury and bronchiolitis obliterans. Chest 104:971–973

    Article  CAS  PubMed  Google Scholar 

  28. Boswell R, McCunney RJ (1995) Bronchiolitis obliterans from exposure to fly ash. JOEM 37:850–855

    CAS  PubMed  Google Scholar 

  29. Markopoulou KD, Cool CD, Elliot TL et al (2002) Obliterative bronchiolitis: varying presentations and clinicopathological correlation. Eur Respir J 19:20–30

    Article  Google Scholar 

  30. Parmet AJ, Von Essen S (2002) Rapidly progressive, fixed airway obstructive disease in popcorn workers: a new occupational pulmonary illness? JOEM 44:216–218

    CAS  PubMed  Google Scholar 

  31. Kreiss K, Gomaa A, Kullman G et al (2002) Clinical bronchiolitis obliterans in workers at a microwave-popcorn plant. N Engl J Med 347:330–338

    Article  PubMed  Google Scholar 

  32. King MS, Eisenberg R, Newman JH et al (2011) Constrictive bronchiolitis in soldiers returning from Iraq and Afghanistan. N Engl J Med 36:222–230

    Article  Google Scholar 

  33. Cullinan P, McGavin CR, Kreiss K et al (2013) Obliterative bronchiolitis in fibreglass workers: a new occupational disease? Occup Environ Med 70:357–359

    Article  PubMed  Google Scholar 

  34. Chen C-H, Tsai P-J, Wang W-C et al (2013) Obliterative bronchiolitis in workers laying up fiberglass-reinforced plastics with polyester resin and methylethyl ketone peroxide catalyst. Occup Environ Med 70:675–676

    PubMed  Google Scholar 

  35. Nett RJ, Edwards NT, Ruder AM et al (2017) Deaths from nonmalignant respiratory disease in styrene-exposed workers: does obliterative bronchiolitis contribute to mortality? Ann Am Thorac Soc 14:810–811

    Article  PubMed  Google Scholar 

  36. Chu H-Q, Liu J-M, Gui T et al (2012) Case of interstitial lung disease possibly induced by exposure to iron dust. Heart Lung 41:196–199

    Article  PubMed  Google Scholar 

  37. Mann JM, Sha KK, Kline G et al (2005) World trade center dyspnea: bronchiolitis obliterans with functional improvement: a case report. Am J Ind Med 48:225–229

    Article  PubMed  Google Scholar 

  38. Akpinar-Elci M, Travis WD, Lynch DA et al (2004) Bronchiolitis obliterans syndrome in popcorn production plant workers. Eur Respir J 24:298–302

    Article  CAS  PubMed  Google Scholar 

  39. Centers for Disease Control (2007) Fixed obstructive lung disease among workers in the flavor-manufacturing industry—California, 2004–2007. Morb Mortal Wkly Rep 56:389–393

    Google Scholar 

  40. van Rooy FGBGJ, Rooyackers JM, Prokop M et al (2007) Bronchiolitis obliterans syndrome in chemical workers producing diacetyl for food flavorings. Am J Respir Crit Care Med 176:498–504

    Article  PubMed  CAS  Google Scholar 

  41. Hendrick DJ (2008) “Popcorn workers lung” in Britain in a man making potato crisp flavouring. Thorax 63:267–268

    Article  CAS  PubMed  Google Scholar 

  42. Modi P, Yadava V, Sreedhar R et al (2008) A case of flavor-induced lung disease. South Med J 101:541–542

    Article  PubMed  Google Scholar 

  43. Cavalcanti ZDR, Filho APL, Pereira CADC et al (2012) Bronchiolitis associated with exposure to artificial butter flavoring in workers at a cookie factory in Brazil. J Bras Pneumol 38:395–399

    Article  Google Scholar 

  44. Egilman DS, Schilling JH (2012) Bronchiolitis obliterans and consumer exposure to butter-flavored microwave popcorn: a case series. Int J Occup Environ Health 18:29–39

    Article  CAS  PubMed  Google Scholar 

  45. Centers for Disease Control (2013) Obliterative bronchiolitis in workers in a coffee-processing facility—Texas, 2008–2012. Morb Mortal Wkly Rep 62:305–307

    Google Scholar 

  46. Fletcher-Leggett ED, White SK, Fedan KR et al (2018) Burden of respiratory abnormalities in microwave popcorn and flavouring manufacturing workers. Occup Environ Med 75:709–715

    Article  Google Scholar 

  47. Devakonda A, Raoof S, Sung A et al (2010) Bronchiolar disorders: a clinical-radiological diagnostic algorithm. Chest 137:938

    Article  PubMed  Google Scholar 

  48. IOM Institute of Medicine (2011) Long-term health consequences of exposure to burn pits in Iraq and Afghanistan. The National Academies Press, Washington DC, pp 31–46

    Google Scholar 

  49. Falvo MJ, Sotolongo AM, Osinubi OY et al (2020) Diagnostic workup of constrictive bronchiolitis in the military veteran. Mil Med 185(11/12):472–475

    Article  PubMed  Google Scholar 

  50. Banks DE, Bolduc CA, Ali SK et al (2018) Constrictive bronchiolitis attributable to inhalation of toxic agents: considerations for a case definition. J Occup Environ Med 60:90–96

    Article  CAS  PubMed  Google Scholar 

  51. Lentz RJ, Fessel JP, Johnson JE et al (2016) Transbronchial cryobiopsy can diagnose constrictive bronchiolitis in veterans of recent conflicts in the Middle East. Am J Resp Crit Care Med 193:806–808

    Article  PubMed  PubMed Central  Google Scholar 

  52. Morris MJ, Dodson DW, Lucero PF et al (2014) Study of active duty military for pulmonary disease related to environmental dust exposure (STAMPEDE). Am J Resp Crit Care Med 190:77–84

    Article  PubMed  Google Scholar 

  53. Morris MJ, Walter RJ, McCann ET et al (2020) Clinical evaluation of deployed military personnel with chronic respiratory symptoms: study of active duty military for pulmonary disease related to environmental deployment exposures (STAMPEDE) III. Chest 157:1559–1567

    Article  PubMed  Google Scholar 

  54. Madar CS, Lewin-Smith MR, Franks TJ et al (2017) Histological diagnoses of military personnel undergoing lung biopsy after deployment to Southwest Asia. Lung 195:507–515

    Article  PubMed  Google Scholar 

  55. Garshick E, Blanc PD (2020) Military deployment and respiratory symptoms: some answers, many questions. Chest 157:1407–1408

    Article  PubMed  Google Scholar 

  56. Garshick E, Abraham JH, Baird CP et al (2019) Respiratory health after military service in southwest Asia and Afghanistan. An official American thoracic society workshop report. Ann Am Thorac Soc 16(8):e1–e16

    Article  PubMed  PubMed Central  Google Scholar 

  57. Weiler BA, Colby TV, Floreth TJ et al (2018) Small airways disease in an operation desert storm deployer: case report and review of the literature on respiratory health and inhalational exposures from Gulf War I. Am J Ind Med 61:793–801

    Article  PubMed  Google Scholar 

  58. Robison SW, Barney JB (2018) When the smoke clears: constrictive bronchiolitis from gulf war exposures. Am J Resp Crit Care Med 197:A3585

    Google Scholar 

  59. Couture C, Colby TV (2003) Histopathology of bronchiolar disorders. Semin Respir Crit Care Med 24(5):489–498. https://doi.org/10.1055/s-2004-815600

    Article  PubMed  Google Scholar 

  60. Schlesinger C, Meyer CA, Veeraraghavan S et al (1998) Constrictive (obliterative) bronchiolitis: diagnosis, etiology, and a critical review of the literature. Ann Diagn Pathol 2:321–334

    Article  CAS  PubMed  Google Scholar 

  61. Ghanei M, Tazelaar HD, Chilosi M et al (2008) An International collaborative pathologic study of surgical lung biopsies form mustard gas-exposed patients. Respir Med 102:825–830

    Article  PubMed  Google Scholar 

  62. Colby TV (1998) Bronchiolitis: pathologic considerations. Am J Clin Path 129:101–109

    Article  Google Scholar 

  63. Ryerson CJ, Olsen S-R, Carlsten C (2015) Fibrosing bronchiolitis evolving from infectious or inhalational acute bronchiolitis: a reversible lesion. Ann Am Thorac Soc 12:1323–1327

    Article  PubMed  Google Scholar 

  64. Parambil JG, Yi ES, Ryu JH (2008) Obstructive bronchiolar disease identified by CT in the non-transplant population: analysis of 29 consecutive cases. Respirology 14:443–448

    Article  PubMed  Google Scholar 

  65. Nena E, Steiropoulos P, Voulgaris A et al (2020) Occupational exposure in constrictive bronchiolitis. Pathol Res Pract. https://doi.org/10.1016/j.prp.2020.153069

    Article  PubMed  Google Scholar 

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Acknowledgements

The authors acknowledge the assistance of Mr. Robert A. B. Bolish in providing the illustration.

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This is unfunded research.

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Authors and Affiliations

  1. Orlando Veterans Administration Medical Center, Room 4H811, 13800 Veterans Way, Orlando, FL, 32827, USA

    Daniel E. Banks

  2. Pulmonary and Critical Care Service, Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, TX, USA

    Michael J. Morris

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DEB and MJM are co-authors of this original manuscript. DEB is responsible for conceptualization, investigation, writing—original work, writing—review & editing. MJM is responsible for Resources, Investigation, Writing—Review and Editing.

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Correspondence to Daniel E. Banks.

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Banks, D.E., Morris, M.J. Inhalational Constrictive Bronchiolitis: The Evolution of our Understanding of this Disease. Lung 199, 327–334 (2021). https://doi.org/10.1007/s00408-021-00466-2

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