Saturday, September 07, 2019

CDC MMWR Early Release: Acute Lung Injury LInked To Vaping

Credit CDC


Earlier today (link) we looked at the latest update on the CDC's investigation into hundreds of suspected or probable cases of acute lung injury linked to e-cigarettes, or `vaping', during which I also mentioned that the MMWR published two early releases yesterday on the topic.

The first report details 5 cases of Lipoid Pnuemonia linked to `vaping' in North Carolina. 
`Lipoid' refers to fats or oils - and while there are other causes - this rare pneumonia is most commonly seen when someone accidentally aspirates an oily substance (e.g. mineral-oil laxative) into the lungs.
While all 5 of the cases reported below had a history of recent use of marijuana oils or concentrates in e-cigarettes, it has been made clear by the CDC that no one substance or product has been linked to all cases.
Outbreak of Electronic-Cigarette–Associated Acute Lipoid Pneumonia — North Carolina, July–August 2019

Early Release / September 6, 2019 / 68

Kevin Davidson, MD1; Alison Brancato, MS1; Peter Heetderks, MD1; Wissam Mansour, MD1; Edward Matheis, MD1; Myra Nario, MS1; Shrinivas Rajagopalan, MD, PhD2; Bailey Underhill, MS1; Jeremy Wininger, MS1; Daniel Fox, MD1 (View author affiliations) View suggested citation

Electronic cigarettes (e-cigarettes) produce an aerosol by heating a liquid that usually contains nicotine, flavorings, and other chemicals that users inhale, a behavior commonly referred to as “vaping.” E-cigarettes can also be used to deliver marijuana and other drugs.

In recent months, more than 200 possible cases of acute lung injury potentially associated with vaping were reported from 25 states (1).

During July and August 2019, five patients were identified at two hospitals in North Carolina with acute lung injury potentially associated with e-cigarette use. Patients were adults aged 18–35 years and all experienced several days of worsening dyspnea, nausea, vomiting, abdominal discomfort and fever. All patients demonstrated tachypnea with increased work of breathing on examination, hypoxemia (pulse oximetry < 90% on room air), and bilateral lung infiltrates on chest x-ray. 

All five patients shared a history of recent use of marijuana oils or concentrates in e-cigarettes. All of the products used were electronic vaping pens/e-cigarettes that had refillable chambers or interchangeable cartridges with tetrahydrocannabinol (THC) vaping concentrates or oils, which were all purchased on the street. Three of the patients also used nicotine-containing e-cigarettes, and two of the patients smoked marijuana or conventional cigarettes, although none used other illicit drugs. All five patients were hospitalized for hypoxemic respiratory failure; three required intensive care for acute respiratory distress syndrome, one of whom required intubation and mechanical ventilation. All of the patients survived.

Diagnosis of lipoid pneumonia among these patients was based on history of using liquids in e-cigarettes that contain sources of lipid, consistent radiologic findings, demonstration of lipid-laden macrophages in respiratory samples, and exclusion of alternative diagnoses. Lipid-laden macrophages are best demonstrated by performing special lipid stains such as oil red O or Sudan staining of cytology from bronchoalveolar lavage (6).
Further investigation of the specific pathogenesis of acute lung injury and inciting factors are warranted to determine whether other cases in the ongoing multistate outbreak (1) bear the same features as the cases described in this report. Patients with lipoid pneumonia might improve on corticosteroids; however, the optimal treatment regimen and duration, as well as the long-term effects of this lung injury, are uncertain (6).

(Continue . . . )

The second MMWR Early Release concerns interim guidance for the public as the CDC's investigation continues:
Severe Pulmonary Disease Associated with Electronic-Cigarette–Product Use — Interim Guidance

Early Release / September 6, 2019 / 68
Joshua G. Schier, MD1; Jonathan G. Meiman, MD2; Jennifer Layden, MD3; Christina A. Mikosz, MD1; Brenna VanFrank, MD4; Brian A King, PhD4; Phillip P. Salvatore, PhD1,5; David N. Weissman, MD6; Jerry Thomas, MD7; Paul C. Melstrom, PhD4; Grant T. Baldwin, PhD1; Erin M. Parker, PhD1; Elizabeth A. Courtney-Long, MSPH4; Vikram P. Krishnasamy, MD1; Cassandra M. Pickens, PhD1; Mary E. Evans, MD1; Sharon V. Tsay, MD1; Krista M. Powell, MD1; Emily A. Kiernan, MD8; Kristy L. Marynak, MPP4; Jennifer Adjemian, PhD9; Kelly Holton1; Brian S. Armour, PhD4; Lucinda J. England, MD10; Peter A. Briss, MD4; Debra Houry, MD1; Karen A. Hacker, MD4; Sarah Reagan-Steiner, MD11; Sherif Zaki, MD11; Dana Meaney-Delman, MD11; CDC 2019 Lung Injury Response Group (View author affiliations) View suggested citation

What is already known about this topic?

Twenty-five states have reported more than 200 possible cases of severe pulmonary disease associated with the use of electronic cigarettes (e-cigarettes).

What is added by this report?

Based on available information, the disease is likely caused by an unknown chemical exposure; no single product or substance is conclusively linked to the disease.

What are the implications for public health practice?

Until a definitive cause is known, persons should consider not using e-cigarettes. Those who use e-cigarettes should seek medical attention for any health concerns. Clinicians should report possible cases to their local or state health department.
       (Continue . . . )

And one more, published yesterday in the New England Journal of Medicine, for good measured.
Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin — Preliminary Report
Jennifer E. Layden, M.D., Ph.D., Isaac Ghinai, M.B., B.S., Ian Pray, Ph.D.,
Anne Kimball, M.D., Mark Layer, M.D., Mark Tenforde, M.D., Ph.D., Livia Navon, M.S., Brooke Hoots, Ph.D., Phillip P. Salvatore, Ph.D., Megan Elderbrook, M.P.H., Thomas Haupt, M.S., Jeffrey Kanne, M.D., Megan T. Patel, M.P.H., Lori Saathoff-Huber, M.P.H., Brian A. King, Ph.D., M.P.H., Josh G. Schier, M.D., Christina A. Mikosz, M.D., M.P.H., and Jonathan Meiman, M.D.

Ten million - mostly young - Americans `vape' regularly, which means we're apt to find the 450 suspected cases reported so far to be the tip of the iceberg.

Stay tuned.