The recent cluster of pulmonary illnesses related to electronic cigarette (e-cigarette) use appears to represent an emerging clinical syndrome or syndromes, according to a case series published in the New England Journal of Medicine.

In July 2019, the Wisconsin Department of Health Services and the Illinois Department of Public Health received reports of pulmonary disease with no clear cause, but that were possibly associated with e-cigarettes and related products, prompting a coordinated public health investigation.

The authors of the case series, some of whom are a part of the investigative team, identified 53 case patients in Wisconsin and Illinois who had reported e-cigarette use within 90 days prior to symptom onset and also had pulmonary infiltrates on imaging. The median age of the patients was 19 years and 83% were men. Generally, the patients were young and healthy. Respiratory symptoms were present in the majority of patients (98%), along with gastrointestinal (81%) and constitutional (100%) symptoms.

The most common respiratory symptoms included cough, shortness of breath, and chest pain. Abnormal chest radiographs were seen in 91% of patients, including 5 pleural effusions, 4 cases of pneumomediastinum, and 1 case of pneumothorax. In addition, 87% of patients demonstrated a significant leukocytosis (median, 15,900/mL3); 94% of these patients also demonstrated a >80% neutrophil predominance.

Nearly all of the patients (94%) were hospitalized and the median duration of stay was 6 days. Most patients received intravenous or oral systemic glucocorticoids as treatment. The investigators confirmed 9 cases of acute respiratory distress syndrome; 2 patients underwent extracorporeal membrane oxygenation and 1 of these patients died.

All patients reported a history of e-cigarette use and related products within 90 days prior to symptom onset. Furthermore, of patients with information regarding the last date of use, 94% reported vaping in the week before their symptoms appeared. Of the 41 patients extensively interviewed, 61% reported using nicotine products, 80% reported using tetrahydrocannabinol (THC) products, and 7% reported using cannabidiol products. About half of the patients (44%) reported using both nicotine and THC products.

The investigators pointed out, “Given the disparate nature of e-cigarette-associated illnesses that have been reported in the literature, it is notable that case patients in Wisconsin and Illinois presented with similar clinical findings and progression of disease, which suggests a similar pathophysiological mechanism of lung injury.”

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Detailed interviews with patients to determine exposure to specific substances and devices will help further narrow the list of agents that may be responsible for the increase in pulmonary disease associated with vaping.

The investigators concluded that their findings support several public health recommendations released by the US Centers for Disease Prevention and Control, including abstaining from e-cigarettes while this investigation is ongoing, particularly from those purchased from sources other than authorized retailers.

Reference

Layden JE, Ghinai I, Pray I, et al. Pulmonary illness related to e-cigarette use in Illinois and Wisconsin — preliminary report [published online September 6, 2019]. N Engl J Med. doi:10.1056/NEJMoa1911614