SESSION TITLE: Occupational and Environmental Lung Disease CasesSESSION TYPE: Rapid Fire Case ReportsPRESENTED ON: 10/18/2022 12:25 pm - 01:25 pmINTRODUCTION: A bulla is an air space in the lung measuring >1 cm in diameter in the distended state. Bullous lung disease (BLD) is the presence of bullae in the lung parenchyma and giant bullae, those occupying at least 30% of a hemithorax. They can develop in advanced COPD with generalized emphysema. BLD is associated with exposure to tobacco smoke or biomass fuel combustion, marijuana and alpha-1-AT deficiency. Burn pits are open areas for burning solid waste and were widely used in US military combat zones before 2009. Emissions can include harmful chemicals and smoke. Exposure has been associated with lung diseases such as asthma, COPD, emphysema, and cancer. We present the case of a veteran with exposure to tobacco and burn pits who had BLD and pneumothorax (PTX).CASE PRESENTATION: A 52-year-old veteran with a history of COPD and smoking 1 pack per day for 20 years presented to the ED with dyspnea and chest pain. CT Chest showed giant emphysematous bullous disease with a moderate left-sided PTX. He reported a right-sided PTX 13 years ago for which he underwent right thoracotomy with bleb resection, after which he quit smoking. He had a history of burn pit exposure (BPE) during deployment in Iraq 30 years prior. He denied marijuana use and tested negative for alpha-1 antitrypsin deficiency. He had no signs of connective tissue disorders or features suggestive of Ehlers-Danlos, Marfans, or Loeys Dietz syndrome. He underwent pigtail catheter placement for PTX with bridge to VATS pleurodesis of the left lung.DISCUSSION: As the patient was 39 at the time of diagnosis, the severity of BLD was thought to be out of proportion to isolated smoking-related lung disease. Given that prolonged exposure to indoor smoke caused by cooking stoves has been associated with COPD and BLD, we posit that burn pit exposure may have posed a similar risk in our patient and worsened his disease. Around 2 million veterans who served in combat zones are estimated to have had BPE but data about it is limited. It is an area of ongoing study, especially since the recent creation of the Airborne Hazards and Open Burn Pit Registry which allowed studies that found BPE is associated with chronic respiratory conditions. Given the sheer magnitude of people potentially at risk for respiratory disease, including advanced COPD leading to BLD, and complications such as PTX (as in our patient), bronchogenic carcinoma, or fluid accumulation within the bulla, our case highlights the need for studies to understand respiratory issues associated with BPE.CONCLUSIONS: Maintaining a high index of suspicion for BLD in high-risk veterans who are smokers and/or have had exposure to burn pits may have implications for early tobacco cessation to prevent worsening of disease, early screening and management of complications such as bronchogenic carcinoma, as well as designation as a service-connected condition and further studies in this area.Reference #1: Abraham, J., Eick-Cost, A., Clark, L., Hu, Z., Baird, C., DeFraites, R., Tobler, S., Richards, E., Sharkey, J, Lipnick, R., & Ludwig, S. (2014). A retrospective cohort study of military deployment and postdeployment medical encounters for respiratory conditions. Mil Med, 179(5), 540-546.Reference #2: Bhatt, S., Kim, Y., Harrington, K., Hokanson, J., Lutz, S., Cho, M., DeMeo, D., Wells, J., Make, B., Rennard, S., Washko, G., Foreman, M., Tashkin, D., Wise, R., Dransfield, M., Bailey, W., & COPDGene Investigators (2018). Smoking duration alone provides stronger risk estimates of chronic obstructive pulmonary disease than pack-years. Thorax, 73(5), 414–421.Reference #3: Liu, J., Lezama, N., Gasper, J., Kawata, J., Morley, S., Helmer, D., & Ciminera, P. (2016). Burn Pit Emissions Exposure and Respiratory and Cardiovascular Conditions Among Airborne Hazards and Open Burn Pit Registry Participants. Journal of Occupational and Environmental Medicine, 58(7), e249–e255.DISCLOSURES: No relevant relationships by Weston BowkerNo relevant relationships by Yuqing GaoNo relevant relationships by Nehan SherNo relevant relationships by Clement SingarajahNo relevant relationships by Joseph Teng SESSION TITLE: Occupational and Environmental Lung Disease Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: A bulla is an air space in the lung measuring >1 cm in diameter in the distended state. Bullous lung disease (BLD) is the presence of bullae in the lung parenchyma and giant bullae, those occupying at least 30% of a hemithorax. They can develop in advanced COPD with generalized emphysema. BLD is associated with exposure to tobacco smoke or biomass fuel combustion, marijuana and alpha-1-AT deficiency. Burn pits are open areas for burning solid waste and were widely used in US military combat zones before 2009. Emissions can include harmful chemicals and smoke. Exposure has been associated with lung diseases such as asthma, COPD, emphysema, and cancer. We present the case of a veteran with exposure to tobacco and burn pits who had BLD and pneumothorax (PTX). CASE PRESENTATION: A 52-year-old veteran with a history of COPD and smoking 1 pack per day for 20 years presented to the ED with dyspnea and chest pain. CT Chest showed giant emphysematous bullous disease with a moderate left-sided PTX. He reported a right-sided PTX 13 years ago for which he underwent right thoracotomy with bleb resection, after which he quit smoking. He had a history of burn pit exposure (BPE) during deployment in Iraq 30 years prior. He denied marijuana use and tested negative for alpha-1 antitrypsin deficiency. He had no signs of connective tissue disorders or features suggestive of Ehlers-Danlos, Marfans, or Loeys Dietz syndrome. He underwent pigtail catheter placement for PTX with bridge to VATS pleurodesis of the left lung. DISCUSSION: As the patient was 39 at the time of diagnosis, the severity of BLD was thought to be out of proportion to isolated smoking-related lung disease. Given that prolonged exposure to indoor smoke caused by cooking stoves has been associated with COPD and BLD, we posit that burn pit exposure may have posed a similar risk in our patient and worsened his disease. Around 2 million veterans who served in combat zones are estimated to have had BPE but data about it is limited. It is an area of ongoing study, especially since the recent creation of the Airborne Hazards and Open Burn Pit Registry which allowed studies that found BPE is associated with chronic respiratory conditions. Given the sheer magnitude of people potentially at risk for respiratory disease, including advanced COPD leading to BLD, and complications such as PTX (as in our patient), bronchogenic carcinoma, or fluid accumulation within the bulla, our case highlights the need for studies to understand respiratory issues associated with BPE. CONCLUSIONS: Maintaining a high index of suspicion for BLD in high-risk veterans who are smokers and/or have had exposure to burn pits may have implications for early tobacco cessation to prevent worsening of disease, early screening and management of complications such as bronchogenic carcinoma, as well as designation as a service-connected condition and further studies in this area. Reference #1: Abraham, J., Eick-Cost, A., Clark, L., Hu, Z., Baird, C., DeFraites, R., Tobler, S., Richards, E., Sharkey, J, Lipnick, R., & Ludwig, S. (2014). A retrospective cohort study of military deployment and postdeployment medical encounters for respiratory conditions. Mil Med, 179(5), 540-546. Reference #2: Bhatt, S., Kim, Y., Harrington, K., Hokanson, J., Lutz, S., Cho, M., DeMeo, D., Wells, J., Make, B., Rennard, S., Washko, G., Foreman, M., Tashkin, D., Wise, R., Dransfield, M., Bailey, W., & COPDGene Investigators (2018). Smoking duration alone provides stronger risk estimates of chronic obstructive pulmonary disease than pack-years. Thorax, 73(5), 414–421. Reference #3: Liu, J., Lezama, N., Gasper, J., Kawata, J., Morley, S., Helmer, D., & Ciminera, P. (2016). Burn Pit Emissions Exposure and Respiratory and Cardiovascular Conditions Among Airborne Hazards and Open Burn Pit Registry Participants. Journal of Occupational and Environmental Medicine, 58(7), e249–e255. DISCLOSURES: No relevant relationships by Weston Bowker No relevant relationships by Yuqing Gao No relevant relationships by Nehan Sher No relevant relationships by Clement Singarajah No relevant relationships by Joseph Teng