Key messages

• It is unknown if patients with a history of e-cigarette or vaping product use associated lung injury (EVALI) are at higher risk for severe complications of influenza or other respiratory viral infections if they are infected simultaneously or after recovering from lung injury.  Healthcare providers should emphasize the importance of vaccination against influenza and pneumococcal disease according to current guidelines.
• Healthcare providers should ask patients about the use of the e-cigarette, or vaping products if they present with symptoms of respiratory or gastrointestinal illness, influenza-like illness (fever and cough/sore throat) or are being reported to public health as an influenza-related ICU admission.
• A chest radiograph (CXR) and or CT should be considered for patients who vape and have respiratory or gastrointestinal symptoms.
• Providers should test for influenza and consider ruling out other infections for patients with suspected EVALI.  Treatment with empiric antimicrobials, including antivirals, should be considered in accordance with established guidelines.
• Corticosteroid treatment may be helpful in treating hospitalized patients with EVALI. Consultation with pulmonary and infectious disease specialists should be considered.
• Providers should advise patients to stop vaping and link them to appropriate cessation services.
• Discharged patients should be advised to re-present if symptoms recur and followed up within 1-2 weeks.
• Outpatient management may be appropriate for some patients with EVALI who have normal oxygen saturations (>95%), no respiratory distress, no comorbidities that might compromise pulmonary reserve, reliable access to immediate care and strong social support systems.  Outpatients should be followed up within 24-48 hours of initial evaluation and advised to seek medical care promptly if respiratory symptoms worsen. 

Background

Public health is responding to reports of vaping-related lung injury both nationally and in Illinois. National case counts and deaths updated every Thursday, can be found here (https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html#latest-outbreak-information). The Chicago Department of Public Health (CDPH) is asking clinical providers to:

1. Report patients with unexplained respiratory illness by faxing this form* to (312) 746-4683 attn: Karrie-Ann Toews
2. Retain vaping products from case-patients for testing
3. Hold clinical samples of bronchoalveolar lavage (BAL) or lung tissue biopsies after processing and sampling for potential submission to the Illinois Department of Public Health (IDPH) laboratory.

Clinical Presentation

Patients often present with cough, shortness of breath, or pleuritic chest pain. Gastrointestinal symptoms such as nausea, abdominal pain, and diarrhea have been common as well as other constitutional symptoms including fever, chills, weight loss, and fatigue. Diagnostic imaging has demonstrated infiltrates similar to atypical pneumonia on chest x-ray and ground-glass opacities on chest CT, both non-specific findings. Infectious, rheumatologic, and other disease process evaluations are negative. Patients have frequently required intensive care admission and ventilator support due to acute respiratory distress syndrome (ARDS) and hypoxia.

Potential Exposures

Patients have all reported vaping in the weeks to months prior to illness. Products used may contain THC, Cannabidiol (CBD), nicotine, flavors and other chemicals. Although the Food and Drug Administration (FDA) has identified Vitamin E acetate in some THC-containing samples, the significance of this is not yet known and, as of 12th September 2019, no single product or device has been conclusively implicated.

Diagnostic Testing and Management

Chest imaging (x-ray or CT) can assist in determining the case status of patients with unexplained respiratory symptoms and vaping exposures (see case definition below).

Consider all causes of illness in patients reporting respiratory and gastrointestinal symptoms (e.g. infectious, rheumatologic, neoplastic) and consultation with specialists (pulmonary, infectious disease, critical care, medical toxicology) as clinically indicated. Infectious disease diagnostics should be determined based on risk factors, but can include:

• Influenza polymerase chain reaction (PCR) testing or alternative influenza testing
• Respiratory pathogen panel (RPP)
• Mycoplasma pneumonia testing (PCR or RPP preferred, can send antibodies if molecular testing is unavailable)
• Legionella urine antigen or legionella respiratory culture
• Streptococcus pneumonia urine antigen
• Blastomycosis antigen or antibodies
• Histoplasmosis antigen or antibodies
• HIV antibody/antigen; viral load if acute HIV suspected
• Blood cultures
• Sputum cultures
• Urine cultures (if indicated)
• If bronchoscopy deemed appropriate for clinical care, recommend sending on BAL fluid:
  • Gram stain and Bacterial cultures
  • Fungal cultures/Potassium hydroxide (KOH) stains
  • Acid-fast bacilli smear and mycobacterial cultures
  • RPP
  • Pneumocystis PCR or Pneumocystis specific stain

Urinary toxicology screening for patients with significant respiratory illness of unclear etiology in whom a reliable vaping history is unavailable is recommended.

Clinical improvement of patients has been reported with corticosteroid use. Currently, there is insufficient outcome evidence to recommend the use of steroids on a routine basis. The decision to use corticosteroids should be made based on risks and benefits and the likelihood of other etiologies. Aggressive supportive care is warranted.

Lipoid pneumonia associated with inhalation of lipids generated by e-cigarettes has been reported based on the detection of lipid-laden alveolar macrophages on BAL and lipid staining, though this finding may be present in other illnesses.

Lung biopsies have been performed on some patients. If a lung biopsy is obtained, lipid staining may be considered during pathologic examination. Conducting routine tissue processing and histopathologic evaluation is still important. Consider consultation with pulmonary and infectious diseases specialists as well as pathologists to inform other testing.

Case Definition

TABLE. 2019 Lung Injury Surveillance Case Definition (CDC) – September 18, 2019

Note: These surveillance case definitions are meant for surveillance and not clinical diagnosis; they are subject to change and will be updated as additional information becomes available if needed.
* Using an electronic device (e.g., electronic nicotine delivery system (ENDS), electronic cigarette (e-cigarette), vaporizer, vape(s), vape pen, dab pen, or other device) or dabbing to inhale substances (e.g., nicotine, marijuana, tetrahydrocannabinol, tetrahydrocannabinol concentrates, cannabinoids, synthetic cannabinoids, flavorings, or other substances).
** Clinical team caring for the patient.

Prevention

At this time, it is not known what product(s), chemicals or devices are linked to these illnesses.

The CDC recommends the following for patients:

1. While this investigation is ongoing, if you are concerned about specific health risks, consider refraining from using e-cigarette products.
2. Regardless of the ongoing investigation, anyone who uses e-cigarette products should not buy these products off the street (e.g., e-cigarette products with THC, other cannabinoids) and should not modify e-cigarette products or add any substances to these products that are not intended by the manufacturer.
3. Regardless of the ongoing investigation, e-cigarette products should not be used by youth, young adults, pregnant women, as well as adults who do not currently use tobacco products. If you use e-cigarette products, monitor yourself for symptoms (e.g., cough, shortness of breath, chest pain) and promptly seek medical attention if you have concerns about your health. CDC and FDA will continue to advise and alert the public as more information becomes available.
4. Adult smokers who are attempting to quit should use evidence-based treatments, including counseling and FDA-approved medications. If you who need help quitting tobacco products, including e-cigarettes, contact your doctor.