August 8, 2003

VUMC physicians treat mustard gas victim

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Dr. Aaron Milstone examines Mohammed Aziz, who endured a mustard gas attack in 1988 in Iraq. He he has been treated at VUMC since 2001. Photo by Dana Johnson

VUMC physicians treat mustard gas victim

Mohammed Aziz still suffers the effects of a mustard gas attack he endured 15 years ago in his native Iraq. Aziz — who has been treated at Vanderbilt since 2001 — is the first proven case of brochiolitis obliterans seen in the United States after exposure to mustard gas, according to a report in the Aug. 6 Journal of the American Medical Association.

Vanderbilt pulmonary physicians are familiar with bronchiolitis obliterans. Considered relatively rare, the disorder causes scarring and inflammation to the lungs. It is most commonly seen in post lung and bone marrow transplant patients, patients with connective tissue disorders, and can arise after complications from certain forms of viral and bacterial infections.

Aziz, 39, is being treated by Vanderbilt pulmonologists Dr. Aaron Milstone, assistant professor of Medicine, Jason Thomason and Todd Rice, both senior fellows in Allergy, Pulmonary and Critical Care Medicine.

Aziz was referred to Vanderbilt for a possible lung transplant from an area hospital. He presented with severe shortness of breath, a constant cough and very low oxygen levels. Upon questioning, doctors learned Aziz’s history — he lived in the Kurdish town of Halabja, which was the target of an Iraqi chemical weapons attack that included mustard gas and nerve agents during the Iran-Iraq War.

“This is the first and probably the only time in our clinical practices to see something like this,” Milstone said. “We were mesmerized by his story.

“When I met him two years ago, I thought he had less than a year to live. I am very impressed with how well he has done. His prognosis is difficult. We are hopeful that with supportive care and antibiotics we will be able to keep him stable so that he can maintain a good quality of life and not require transplant for another two to five years.”

Aziz is presently taking high-dose steroids and antibiotics to suppress the inflammation. He agrees that since beginning treatment under Drs. Milstone, Thomason and Rice that his health has greatly improved.

“It’s interesting, when I first came to Nashville, no one would take my illness seriously,” Aziz said through an interpreter, Aram Khoshnaw. “I didn’t get the service I needed until I was really, really sick. It took about six months. Now, I can walk, there is less coughing, my quality of life has improved considerably.”

Aziz, who has no history of smoking or lung problems, describes the day of the attack – which is also documented in the JAMA report.

A student at Baghdad University, he was home visiting his parents. He recalls rushing to the basement of their home for safety.

“We gathered ourselves and tried to escape,” he said. “The children and elders were nauseated, vomiting and blind. But after two hours I had the same side effects. I lost my [eyesight] for almost a month. Led by friends about six kilometers (4 miles), I escaped. It was horrible going through the Iran border hearing death, people falling, people dying along the way.”

Within hours of the attack, 15 family members were dead. A reported 5,000 people died the day of the attack and up to 12,000 died in the days following.

Aziz was taken to New York for treatment through the Red Crescent Service of Iran, where he later returned to live in a refugee camp. In 1991 he returned home to Halabja to help rebuild the town.

In 1998 he left for Syria, where he spent two years awaiting immigration status. He was resettled in Nashville in 2000.

Although Aziz is the first documented case of BO as a direct result of chemical warfare, Vanderbilt physicians assume that this condition exists in other Kurds living in Halabja — but no cases have yet been reported in the U.S.

“Because Mr. Aziz says his parents, who remain in Halabja, have similar but less severe problems, we feel certain that other case exist.” Thomason said. “Of course, it is extremely difficult for these patients to gain access to a facility such as Vanderbilt in order to obtain a comprehensive evaluation and treatment plan,” he said. “This is the first time we have had the privilege of caring for such a patient.”

Milstone said this case has been a real eye-opener and shows just how little the U.S. knows about bioterrorism.

“It does happen. It’s out there. It just hasn’t happened here.”The recommendation from the report is that “BO from toxic fume inhalation can occur after mustard gas exposure and should be considered in patients who have compatible clinical presentations.”