Clinical, Bronchoscopic, and Imaging Findings of e-Cigarette, or Vaping, Product Use–Associated Lung Injury Among Patients Treated at an Academic Medical Center

Scott K Aberegg,Meghan M Cirulis,Sean D Maddock,Andrew Freeman,Cheryl S Pirozzi,Lynn M Keenan,Sanjeev M Raman,Joyce Schroeder,Sean J Callahan,Howard Mann

doi:10.1001/jamanetworkopen.2020.19176

Abstract

e-Cigarette, or vaping, product use-associated lung injury (EVALI) has caused more than 2800 illnesses and 68 deaths in the United States. Better characterization of this novel illness is needed to inform diagnosis and management. To describe the clinical features, bronchoscopic findings, imaging patterns, and outcomes of EVALI. This case series of 31 adult patients diagnosed with EVALI between June 24 and December 10, 2019, took place at an academic medical center in Salt Lake City, Utah. e-Cigarette use, also known as vaping. Symptoms, laboratory findings, bronchoscopic results, imaging patterns, and clinical outcomes. Data from 31 patients (median [interquartile range] age, 24 [21-31] years) were included in the study. Patients were primarily men (24 [77%]) and White individuals (27 [87%]) who used e-cigarette products containing tetrahydrocannabinol (THC) (29 [94%]). Patients presented with respiratory (30 [97%]), constitutional (28 [90%]), and gastrointestinal (28 [90%]) symptoms. Serum inflammatory markers were elevated in all patients. Bronchoscopy was performed in 23 of 28 inpatients (82%) and bronchoalveolar lavage (BAL) revealed the presence of lipid-laden macrophages (LLMs) in 22 of 24 cases (91%). BAL samples tested positive for Pneumocystis jirovecii (3 patients [13%]), rhinovirus (2 patients [8%]), human metapneumovirus and Aspergillus (1 patient each [4%]); all except human metapneumovirus were determined to be false-positives or clinically inconsequential. The exclusive or dominant computed tomography (CT) pattern was organizing pneumonia in 23 of 26 cases (89%). Patients received antibiotics (26 [84%]) and corticosteroids (24 [77%]), and all survived; 20 patients (65%) seen in follow-up showed marked improvement, but residual symptoms (13 [65%]), radiographic opacities (8 [40%]), and abnormal pulmonary function tests (8 of 18 [44%]) were common. In this case series, patients with EVALI characteristically presented with a flu-like illness with elevated inflammatory markers, LLMs on BAL samples, and an organizing pneumonia pattern on CT imaging. Bronchoscopic testing for infection had a high incidence of false-positive results. Patients had substantial residual abnormal results at early follow-up. These data suggest a limited role for bronchoscopy in typical presentations of EVALI without risk factors for alternative diagnoses and the need for careful longitudinal follow-up.

Highlights

In this case series, patients with EVALI characteristically presented with a flu-like illness with elevated inflammatory markers, lipid-laden microphage. SI conversion factors (LLM) on Bronchoalveolar lavage (BAL) samples, and an organizing pneumonia pattern on computed tomography (CT) imaging
Meaning The findings of this study suggest that EVALI has a characteristic clinical and radiographic presentation and that bronchoscopy has limited utility in its evaluation
Bronchoalveolar lavage (BAL) specimens from this and subsequent patients revealed the presence of lipid-laden microphages (LLMs), which led to suspicion the illness was a form of exogenous lipoid pneumonia.[2,22]

Summary

Introduction

In early 2019, a flu-like illness associated with the use of e-cigarettes was identified in the United States.[1,2,3,4,5] Since that time, more than 2800 cases of e-cigarette, or vaping, product use–associated lung injury (EVALI) have been reported to the US Centers for Disease Control and Prevention (CDC), resulting in at least 68 deaths.[6,7,8,9,10,11] Our understanding of this syndrome is based on 4 large patient series, which together comprised approximately 315 patients, less detailed CDC data, and some smaller case series.[1,8,12,13,14,15,16,17,18,19,20] Despite these reports, numerous uncertainties remain, including information on bronchoscopic findings, characteristic radiographic patterns, and longitudinal outcomes.Utah has experienced among the highest per capita EVALI rates in the United States.[10,21] The University of Utah Medical Center (UUMC) is a quaternary care academic medical center in Salt Lake City, Utah, serving a large referral area. In early 2019, a flu-like illness associated with the use of e-cigarettes was identified in the United States.[1,2,3,4,5] Since that time, more than 2800 cases of e-cigarette, or vaping, product use–associated lung injury (EVALI) have been reported to the US Centers for Disease Control and Prevention (CDC), resulting in at least 68 deaths.[6,7,8,9,10,11] Our understanding of this syndrome is based on 4 large patient series, which together comprised approximately 315 patients, less detailed CDC data, and some smaller case series.[1,8,12,13,14,15,16,17,18,19,20] Despite these reports, numerous uncertainties remain, including information on bronchoscopic findings, characteristic radiographic patterns, and longitudinal outcomes. Most of the first 31 patients seen at UUMC underwent bronchoscopy with extensive molecular and microbiological testing during the first 5 months of the outbreak

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Conclusion