All up in smoke: vaping-associated lung injury

Figures & data

Table 1. Patient demographics, smoking, and vaping history

Case Number	1	2	3
Age	50	33	35
Gender	Female	Male	Male
Race	White	White	African American
Marital status	Single	Single	Single
Employment status	Unemployed	Full-time	Unemployed
Smoking history	Former smoker, about 35PY, quit 4 months ago and started E-cigarettes; no marijuana.	Never smoker; no marijuana.	Former smoker, about 0.25pack/day, quit 1.5 years ago; smokes marijuana daily since then.
Length of vaping history	4 months	2 years	One episode of vaping 2 months before admission, with dyspnea thereafter
Product	Unknown	THC	Marijuana
Last day of vaping	Unknown	One day prior to admission	The day before admission
Brand	Unknown	Changed supplier recently	Unknown

Table 2. All three patients were relatively young (age < 50), of mixed gender (2/3 male, 1/3 female), and mixed race (2/3 Caucasian, 1/3 African American). All had a prior vaping history utilizing non-THC and THC-containing products for a range of 4 months to 2 years. The onset of the symptoms consistently occurred following the vaping of products of unknown origin purchased illicitly. Abbreviations: PY – pack years; THC – tetrahydrocannabinol.

Table 2. Clinical characteristics of vaping cases

Case Number	1	2	3
Smoking History	Former smoker, 35 PY	Never smoker	Former smoker: cigarettes 0.25packs per day, quit 1.5 years ago; smoke marijuana daily.
History of lung diseases	No	No	No
Constitutional symptoms	Fever, hot flashes, sweaty,	Fever and chills, significant night sweats, unintentionally weight loss of 18–20lbs over the past week.	Some night sweats, unintentional weight loss of 10lb
Duration of disease onset before admission	5 days	2 months	2 months
Vital signs	Maximum Temperature 39.1C	Maximum Temperature 38C, Maximum Heart Rate 133 bpm, Maximum Respiratory Rate 53 b/m	Unremarkable
Respiratory symptoms	SOB, dry cough, Pleural chest pain (L > R)	Cough, dyspnea	Exertional dyspnea, cough, chest pain when coughing
Non-respiratory symptoms	None	Nausea, projectile vomiting, and watery diarrhea	None
GI symptoms	None	Yes	None
Physical exam	Bibasilar cackles	Diffuse crackles, more pronounced bibasilar, L > R	Diffuse crackles bilaterally, no wheeze
Significant Labs	WBC 16.4 k, Na 131	Na 133, K 3.0, WBC 9.2->17.8 k,	PaO2 68 mmHg, CRP 12
Transaminitis	No LFT results available	AST 35, ALT 53	Normal AST 19, ALT 22
CXR on admission	Hazy bilateral basilar opacities	Punctate high density over the left upper chest, possible minimal infiltrate at posterior lower lung	Extensive opacities seen throughout bilateral lungs, predominantly throughout the upper lobes and peripheral distribution. Patchy changes seen within the perihilar lower lobes.
Chest CT	Enlarged prevascular node (1.2 × 1.8 cm), prominent precarinal LN, prominent Rt hilar LN. Diffuse bilateral GGO	Bilateral infiltrates of somewhat ground-glass in appearance with interstitial and septae, and some precarinal and subcarinal adenopathy.	Scattered ground-glass attenuation with superimposed interlobular septal thickening and areas of confluent airspace opacities bilaterally
Infectious Disease Workup	Negative	Negative	Negative
Bronchoscopy	Yes	No	No
BAL	Negative for malignancy and infection	No	No
Biopsy	EBUS: S7: negative for tumor and granuloma. Lingula biopsy: negative bacterial and fungal cultures	No	No
Treatment	Antibiotics: ceftriaxone, doxycycline; Steroids: Prednisone 60 mg once a day for 4 days	Antibiotics: Ceftriaxone; Steroids: Methylprednisolone 50 mg twice a day for 4 days, then 40 mg once a day for 1 day;	Antibiotics: Ceftriaxone and azithromycin; Steroids: methylprednisolone 60 mg three times a day for 2 days, prednisone 40 mg with 4 weeks taper
Response to treatment	Oxygen demands decreased after steroids X 2d	One day after initiated steroids	One days after initiated steroids
Length of hospital stay	4 days	6 days	3 days
Primary Dx on admission	Sepsis	Nausea and vomiting due to gastroenteritis	Dyspnea on exertion
Primary Dx on discharge	Vaping induced lung injury	Vaping induced lung injury	Pulmonary infiltrates

Table 1. All three patients had no previous lung disease. Onset of acute symptoms started between 5 days to 2 months prior to admission. One of three patients had neutrophil-dominant leukocytosis. All three patients demonstrated radiologic abnormalities as above. One patient underwent bronchoscopy, bronchoalveolar lavage, and lung biopsy; while macrophages and other inflammatory cells were seen on BAL, no specific underlying pathology was identified. All patients demonstrated symptomatic and radiographic improvement following steroid administration. Abbreviations: BAL - Bronchoalveolar lavage; bpm – beats per minute; b/m - breaths per minute; CT – computed tomography; EBUS - Endobronchial ultrasound; GGO – ground glass opacities; LN – lymphadenopathy; PY – pack years.

Figure 1. Chest X ray. Chest radiographs depicting a spectrum of EVALI. (a) and (b) Chest radiographs of case 1. (a) (Day 1 of admission, pre-treatment), revealed bi-basilar haziness whereas (b) (steroid day 2), demonstrated mild improvement of left lower lobe infiltrates. (c–e) Chest radiographs of case 2. (c, d) (Day 1 of admission, pre-treatment), revealed minimal infiltrates bilaterally. Punctate density of the left upper chest is suggestive of a calcified granuloma (c), with lateral view (d) showing minimal infiltrate. (e) (steroid day 3), demonstrates clinical improvement in bilateral infiltrates. (f) Chest radiograph of case 3. (f) (Day 1 of admission, pre-treatment), revealed patchy infiltrates bilaterally

Figure 2. CT scans: computerized tomography of chest, showing a spectrum of EVALI in axial and coronal views. (a, b) Chest CT images of case 1 on admission, pre-treatment. (a) revealed bilateral ground glass opacities and interstitial infiltrates. (b) revealed prominent right hilar lymph nodes and an enlarged intrathoracic node. (c–f) Chest CT images of case 2. (c, d) (on admission, pre-treatment) demonstrating bilateral ground glass infiltrates. (e, f) (steroid day 4) showing significant improvement of lung infiltrates bilaterally. (g, h) Chest CT images of case 3 on admission, pre-treatment. (g) demonstrating diffuse patchy ground-glass opacities bilaterally. (h) showing mediastinal lymphadenopathy and interstitial infiltrates bilaterally. (i, j) Chest CT images of an asymptomatic patient with vaping history. CT images showed mild diffuse ground-glass opacities bilaterally

Figure 3. Histopathology. (a) Cytology from bronchoalveolar lavage fluid of case 1. The hollow arrows point to few non-vacuolated foamy macrophages, without droplet deposition. The black arrow points to one bronchial cell. (b) Pathology from lung biopsy of case 1. Minimal tissue. There is no alveolar damage observed