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MEDICAL YEAR
IN REVIEW

smoking cessation program which included fatigue. Vital signs demonstrated tachycar- single agent was used (80%), but many
nicotine replacement by means of nicotine- dia, tachypnea, and hypoxemia. Median du- cases involved the use of 2 or more agents,
based e-cigarettes, versus other means of ration of symptoms prior to admission was such as nicotine and THC together. Since
nicotine replacement. The 1-year absti- 6 days. Laboratory findings included leuko- the makeup of many of the commercial liq-
nence rate was validated biochemically at cytosis, elevated erythrocyte sedimentation uids is unknown, there may be products in
the last visit; 18% of the e-cigarette group rate, and normal procalcitonin levels. All the carrier liquids that need further study.
were abstinent, versus 9.9% of those using have had bilateral infiltrates, either on chest Declared components in nicotine-based va-
other nicotine products. Public Health Eng- radiographs or CT scans. Glucocorticoid ping agents include propylene glycol and
land, an executive agency of Public Health therapy was administered in 92% of the glycerin as well as nicotine. When commer-
and Social Care of the United Kingdom has cases; 65% were thought to have improved cial vaping products have been analyzed,
posted in the British Medical Journal that with glucocorticoid therapy. Lung biopsies contaminants identified have included ni-
“e-cigarettes are 95% safer than smoking”. were available in 17 cases; findings included trosamines, toxic metals, and aromatic hy-
acute fibrinous pneumonitis, diffuse alveo- drocarbons. The flavoring compounds 2,3
E-CIGARETTE/VAPING - lar damage, and organizing pneumonia, pentanedione and diacetyl are of particular
ASSOCIATED LUNG INJURY usually with bronchiolitis. Foamy interest (as noted above, diacetyl has been
(EVALI) macrophages and pneumocyte vacuoliza- identified as the cause of “popcorn lung”,
In mid-summer of 2019, the Illinois and tion were present in all. None of the biop- in which the pathologic findings of bron-
Wisconsin health authorities initiated a co- sies demonstrated findings of lipoid chiolitis obliterens have been similar to
ordinated investigation into an apparent pneumonia, which previously had been those in the few available biopsies in
cluster of cases of severe lung injury in raised as a possibility. EVALI patients).
young healthy persons who reported recent
e-cigarette use, and who presented with CDC RECOMMENDATIONS FOR CURRENT CDC
dyspnea, cough, pulmonary infiltrates, and CASE IDENTIFICATION RECOMMENDATIONS:
for which there was no evidence of infec- Confirmed case: 1. As products containing THC, especially
tion or other cause for the findings. In col- 1. Use of vaping within 90 days before when obtained off the street or from
laboration with the CDC, these symptoms. family and friends, are linked to a major-
observations were published in the Septem- 2. Bilateral pulmonary infiltrates. ity of reported EVALI cases; persons
ber 6, 2019 issue of NEJM, which de- 3. Absence of pulmonary infection (nega- should not use e-cigarettes obtained in
scribed 53 cases: median age was 19, 83% tive viral panel, urine antigen for S. pneu- that manner.
were male, and all presented with bilateral monia and Legionella, negative PCR for 2. Persons should not add any substances
pulmonary infiltrates, respiratory com- influenza, and negative sputum culture to a commercially-purchased e-cigarette.
plaints, and constitutional symptoms. Of or broncholalveolar lavage if done). 3. Although only a small percentage of pa-
these, 94% were hospitalized, 32% required 4. No underlying condition which is plau- tients with EVALI reported use of only
intubation, and one died. A total of 84% sible as an etiology (cardiac, rheumato- nicotine in their vaping, CDC recom-
reported recent use of THC via vaping. logic, neoplastic). mends not using nicotine-containing e-
CDC has since been receiving new reports Probable case: cigarettes.
from 49 states and the District of Colum- 1. Use of vaping within 90 days before 4. CDC recommends that youths, young
bia, totaling 1604 cases as of October 22, symptoms. adults and pregnant women not vape.
2019 with 34 deaths, some of whom had 2. Bilateral pulmonary infiltrates.
used THC products exclusively. 3. Clinical team finds no plausible alterna- John R. Holcomb, MD is board certified in Pul-
tive diagnosis. monary Diseases, Internal Medicine and Critical
CLINICAL FEATURES Care Medicine and is a past President and member
Symptoms at presentation have included POTENTIAL CAUSATIVE AGENTS of the Bexar County Medical Society.
dyspnea, chest pain, cough, nausea and THC is the most common exposure
vomiting, hemoptysis, subjective fever, and identified in the available reports when a

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