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A case of acute lung injury due to an e-cigarette

Tasaduksultan Khan, Abdullah Bin Huda, Maithem Al-jibury and Zeyarmyo Tin
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DOI: https://doi.org/10.7861/clinmed.22-4-s16
Clin Med July 2022
Tasaduksultan Khan
AUniversity Hospitals of Morecambe Bay NHS Foundation Trust, Morecambe, UK
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Abdullah Bin Huda
BLeicester Royal Infirmary, Leicester, UK
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Maithem Al-jibury
AUniversity Hospitals of Morecambe Bay NHS Foundation Trust, Morecambe, UK
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Zeyarmyo Tin
AUniversity Hospitals of Morecambe Bay NHS Foundation Trust, Morecambe, UK
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Introduction

Although considered to be by some as a safer alternative to smoking, electronic cigarettes (e-cigarettes) are associated with significant, even life-threatening, complications; for example, e-cigarette or vaping product use-associated lung injury (EVALI) especially in older patients with pre-exiting respiratory and cardiovascular comorbidities.1–3 We present an interesting case of a patient who was admitted with confusion, fever, cough and breathlessness with raised inflammatory markers and bilateral radiologic abnormalities on chest imaging.

Case presentation

A woman aged in her 40s presented with 1-week history of fever, cough, shortness of breath and confusion. She was normally fit and well with past medical history of asthma, anxiety and Lown–Ganong–Levine syndrome. Her usual medications included salbutamol metered dose inhaler and sertraline. There was no history of recent travel, flu-like illness, use of recreational drugs or trauma. In the previous few months, she had started to vape an e-cigarette and she drank alcohol in moderation. On examination, she was alert but confused with no focal neurology and no signs of meningism. Chest auscultation revealed bilateral crackles. The rest of the examination was normal. Chest X-ray showed widespread, bilateral pulmonary infiltrates, consisting of a mixture of ill-defined and nodular opacities (Fig 1). Routine blood tests showed raised inflammatory markers with C-reactive protein (CRP) of 161 mg/L, white cell count of 11.3 × 109/L and neutrophil count of 9.3 × 109/L. There was patchy bilateral consolidation involving all the lobes in the computed tomography (CT) of the chest (Fig 2) along with enlarged bilateral hilar and mediastinal nodes. CT of the head, magnetic resonance imaging of the head and CT of the abdomen and pelvis were nil acute. Blood and urine culture had no growth. Viral respiratory panel; chlamydophilla; mycoplasma serology; anti-HIV antibodies; pneumococcal and Legionella urinary antigen; and vasculitic and connective tissue disease screens were all negative. Electrocardiography and 2D echocardiography were within normal limits. The patient was started on broad spectrum antibiotics and high-dose oral prednisolone with rapid clinical improvement. Repeat chest imaging was done after 2 weeks of onset of symptoms and this showed that the lungs were clear, with preserved volume and satisfactory mediastinal and hilar shadows.

Fig 1.
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Fig 1.

Posteroanterior X-ray of the chest.

Fig 2.
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Fig 2.

Axial computed tomography of the chest.

Results

Although EVALI is a diagnosis of exclusion, rapid resolution of symptoms and radiological findings with high-dose corticosteroids and ruling out alternative diagnoses confirmed the diagnosis of EVALI.

Conclusion

Due to variable presentation of EVALI, there is no consensus regarding its diagnostic criteria.4,5 Case definition stipulates that, to diagnose EVALI, there should be a history of use of an e-cigarette in the previous 90 days along with lung opacities on chest imaging, exclusion of lung infection based on negative influenza PCR, viral respiratory panel and urine antigen tests for Legionella and Streptococcus pneumoniae, blood cultures, sputum culture, bronchoalveolar lavage and testing for HIV-related opportunistic infections and absence of a likely alternative diagnosis (eg cardiac, neoplastic or rheumatologic).6 Even though underlying pathogenesis of EVALI remains elusive, multiple potential toxins have been highlighted including vitamin E acetate, tetrahydrocannabinol, nicotine and others.7,8 Risk factors for more severe disease include obesity, increasing age, history of asthma and cardiac disease.3 Due to widespread usage of e-cigarettes, clinicians should be vigilant regarding this serious respiratory illness that can be life threatening.9,10

  • © Royal College of Physicians 2022. All rights reserved.

References

  1. ↵
    1. Layden JE
    , Ghinai I, Pray I, et al. Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin - Final Report. N Engl J Med 2020;382:903–16.
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  2. ↵
    1. Kligerman S
    , Raptis C, Larsen B, et al. Radiologic, pathologic, clinical, and physiologic findings of electronic cigarette or vaping product use-associated lung injury (EVALI): evolving knowledge and remaining questions. Radiology 2020;294:491–505.
    OpenUrlPubMed
  3. ↵
    1. Werner AK
    , Koumans EH, Chatham-Stephens K, et al. Hospitalizations and Deaths Associated with EVALI. N Engl J Med 2020;382:1589–98.
    OpenUrlCrossRefPubMed
  4. ↵
    1. Thota D
    , Latham E. Case report of electronic cigarettes possibly associated with eosinophilic pneumonitis in a previously healthy active-duty sailor. J Emerg Med 2014;47:15–7.
    OpenUrlCrossRefPubMed
  5. ↵
    1. Viswam D
    , Trotter S, Burge PS, Walters GI, et al. Respiratory failure caused by lipoid pneumonia from vaping e-cigarettes. BMJ Case Rep 2018;2018:bcr2018224350.
    OpenUrlCrossRefPubMed
  6. ↵
    1. Schier JG
    , Meiman JG, Layden J, et al. Severe pulmonary disease associated with electronic-cigarette-product use - interim guidance. MMWR Morb Mortal Wkly Rep 2019;68:787–90.
    OpenUrlCrossRefPubMed
  7. ↵
    1. Butt YM
    , Smith ML, Tazelaar HD, et al. Pathology of vaping-associated lung injury. N Engl J Med 2019;381:1780–1.
    OpenUrlPubMed
  8. ↵
    1. Ghinai I
    , Pray I, Navon L, et al. E-cigarette product use, or vaping, among persons with associated lung injury - Illinois and Wisconsin, April-September 2019. MMWR Morb Mortal Wkly Rep 2019;68:865–9.
    OpenUrlCrossRef
  9. ↵
    1. Office for National Statistics
    . E-cigarette use in Great Britain. ONS, 2021. www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/drugusealcoholandsmoking/datasets/ecigaretteuseingreatbritain
  10. ↵
    1. Centers for Disease Control and Prevention
    . Outbreak of lung injury associated with the use of e-cigarette, or vaping, products. CDC, 2020. www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html#latest-information [Accessed on 06 December 2021].
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A case of acute lung injury due to an e-cigarette
Tasaduksultan Khan, Abdullah Bin Huda, Maithem Al-jibury, Zeyarmyo Tin
Clinical Medicine Jul 2022, 22 (Suppl 4) 16-17; DOI: 10.7861/clinmed.22-4-s16

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A case of acute lung injury due to an e-cigarette
Tasaduksultan Khan, Abdullah Bin Huda, Maithem Al-jibury, Zeyarmyo Tin
Clinical Medicine Jul 2022, 22 (Suppl 4) 16-17; DOI: 10.7861/clinmed.22-4-s16
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