E-cigarette lung damage manifests as a range of lung problems

By Gene Emery

NEW YORK (Reuters Health) - 9/9/2019

Vaping-related lung damage can initially present as a variety of conditions such as acute eosinophilic pneumonia, lipoid pneumonia and organizing pneumonia, according to researchers.

Other lung diseases linked to e-cigarette use include diffuse alveolar damage, acute respiratory distress syndrome hypersensitivity pneumonitis, diffuse alveolar hemorrhage and giant-cell interstitial pneumonitis, Dr. Jennifer Layden of the Illinois Department of Public Health in Chicago and colleagues report in the September 6 New England Journal of Medicine.

The team identified 53 cases in Illinois and Wisconsin and found that 98% of patients with a confirmed case of severe pulmonary disease associated with e-cigarette use had respiratory symptoms, 81% reported gastrointestinal symptoms and all had constitutional symptoms such as feeling feverish or chilled.

They defined case patients as people who reported using e-cigarette devices and related products in the 90 days before symptom onset, who had pulmonary infiltrates on imaging and whose illness was not attributed to other causes.

At least four deaths in four states, plus 215 cases of severe lung damage in 25 states, have been linked to vaping, with 450 cases of lung illness under investigation throughout the U.S. by the Centers for Disease Control and Prevention.

The cause is unknown and health officials are urging consumers to cease using e-cigarettes until the mystery has been unraveled.

"E-cigarettes should never be used by youths, young adults, pregnant women and adults who do not currently use tobacco products," write Dr. Layden and her colleagues.

And although nicotine vaping has been marketed as a way to wean people off cigarettes, "adult smokers who are attempting to quit should consult their health care provider and use proven treatments," the team adds.

A key complication of the investigation is that symptoms can be diverse and vapers use a wide variety of products.

Among the 53 cases investigated in Illinois and Wisconsin since the outbreak was noticed in July, 84% of the patients used products containing tetrahydrocannabinol (THC), the main psychoactive compound in marijuana.

Yet 17% of the people who fell ill said they were exclusively using nicotine-based products; 44% said they had vaped both THC and nicotine products.

Active infection "does not appear to explain the clinical presentation, but acute toxic lung injury does seem to fit," Dr. David Christiani, of the Harvard T.H. Chan School of Public Health in Boston, observed in an accompanying editorial.

He noted that apart from nicotine, carbonyls, volatile organic compounds such as benzene and toluene, particles and trace metals have all been found in e-cigarette fluids.

The Layden team says getting information on product use can be especially difficult if a vaper doesn't want to admit to using an illegal product, such as the THC-based oils and waxes that are easy to obtain despite being outlawed in most states.

"The content of these products is largely unknown and unregulated," they point out.

Among the cases identified in Wisconsin and Illinois, "patients thus far have had clinical improvement with systemic glucocorticoid therapy, and the majority of patients have received prolonged courses," they write. About one in five U.S. high school students vape, compared with just 3.2% in the adult population.

In Wisconsin, doctors at Children's Hospital in Wisconsin notified the state on July 10 after admitting five previously healthy adolescent e-cigarette users who had dyspnea, fatigue and hypoxemia. Two required intubation and mechanical ventilation. Four had ground-glass opacities concentrated in the lower lobes of the lungs.

Among the 53 cases, 83% were male, the median age was 19, 82% were white, 17% only vaped with nicotine, 37% only vaped with THC and 7% vaped with cannabidiol, one of the most prevalent active ingredients of marijuana but one that does not cause a high.

Once at the hospital, the patients said they had suffered with symptoms for a median of six days. One person had been ill for 61 days.

Upon presentation, 69% had an oxygen saturation rate of less than 95% while breathing ambient air; 31% had a rate below 89%.

Eighty seven percent complained of shortness of breath, 83% had a cough, 55% had chest pain and 11% were coughing up blood.

Among gastrointestinal symptoms, 70% reported nausea, 66% said they had vomited, 43% had abdominal pain and 43% had diarrhea.

Rates were 81% for subjective fever (29% actually had a fever at triage), 58% for chills, 45% for fatigue or malaise and 40% for headache. Sixty-four percent had tachycardia.

All had bilateral infiltrates as seen on chest X-ray or CT and 87% had leukocytosis.

One of the 53 patients died, 31 were admitted to intensive care, 17 were intubated or put on mechanical ventilation and 46 were put on supplemental oxygen.

The Layden team found that 72% of the patients had sought medical care for their symptoms before being admitted to the hospital, with 45% getting an antibiotic because their doctor thought they were suffering from a respiratory-tract infection.

SOURCES: https://bit.ly/2lXrIlA, https://bit.ly/2k5bA0S, https://bit.ly/2m4nbhp and https://bit.ly/2k5rb0q

N Engl J Med 2019.

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