Vaping-Related Lung Injury

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, Cannabadiol (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 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 pneumoniae testing (PCR or RPP preferred, can send antibodies if molecular testing is unavailable)
  • Legionella urine antigen or legionella respiratory culture
  • Streptococcus pneumoniae 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 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

Case classification Criteria
Confirmed

Using an e-cigarette (“vaping”) or dabbing* during the 90 days before symptom onset

AND

Pulmonary infiltrate, such as opacities on plain film chest radiograph or ground-glass opacities on chest CT

AND

Absence of pulmonary infection on initial work-up: Minimum criteria are:

1) negative respiratory viral panel,

AND

2) negative influenza  PCR or rapid test if local epidemiology supports testing.

AND

3) All other clinically indicated respiratory infectious disease testing (e.g., urine antigen for Streptococcus pneumoniae and Legionella, sputum culture if productive cough, bronchoalveolar lavage culture if done, blood culture, human immunodeficiency virus–related opportunistic respiratory infections if appropriate) must be negative

AND

No evidence in medical record of alternative plausible diagnoses (e.g., cardiac, rheumatologic, or neoplastic process).

Probable

Using an e-cigarette (“vaping”) or dabbing* in 90 days before symptom onset

AND

Pulmonary infiltrate, such as opacities on plain film chest radiograph or ground-glass opacities on chest CT

AND

Infection identified via culture or PCT, but clinical team** believes this is not the sole cause of the underlying respiratory disease process OR minimum criteria to rule out pulmonary infection not met (testing not performed) and clinical team** believes infection is not the sole cause of the underlying respiratory lung injury

AND

No evidence in medical record of alternative plausible diagnoses (e.g., cardiac, rheumatologic, or neoplastic process).

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.

Reporting

For cases of unexplained respiratory illness, please fax this case report form  and this survey completed by the patient (or proxy) to (312) 746-4683 attn: Karrie-Ann Toews.

If patient unable to complete survey due to clinical status, it is okay to send case form initially and provide survey at a later date. 

For questions or to discuss a suspect case, please email vaping@cityofchicago.org (without patient identifiers).

 

Submissions

Submission of BAL or Tissue Samples to IDPH

BAL or tissue specimens can be sent to the IDPH lab on ice packs with a completed IDPH Laboratory Requisition Form. Please indicate outbreak # IL2019-0399 on the submission so that we may correctly assign these samples to this investigation. "Other test" can be marked for type of testing to be performed with the follow up description left blank.

Please email vaping@cityofchicago.org (without patient identifiers) or call 312-746-6152 so that we can inform the laboratory of expected specimens.
Illinois Department of Public Health Laboratory
Attn: Dr. Mohammed Nasir
2121 W. Taylor Street
Chicago, IL 60612

Submission of Vaping Products

Please email vaping@cityofchicago.org (without patient identifiers) for questions and coordination related to the submission of any vaping products. You will be contacted for further instructions.