Evaluation of Bronchoalveolar Lavage Fluid from Patients in an Outbreak of E-cigarette, or Vaping, Product Use–Associated Lung Injury — 10 States, August–October 2019

Blount, Benjamin C.; Karwowski, Mateusz P.; Morel-Espinosa, Maria; Rees, Jon; Sosnoff, Connie S.; Cowan, Elizabeth A.; Gardner, Michael L. G.; Wang, Lanqing; Valentín-Blasini, Liza; Silva, Lalith; Jesús, Víctor R. De; Kuklenyik, Zsuzsanna; Watson, Cliff; Seyler, Tiffany; Xia, Baoyun; Chambers, David M.; Briss, Peter A.; King, Brian A.; Delaney, Lisa; Jones, Christopher M.; Baldwin, Grant T.; Barr, John R.; Thomas, Jerry; Pirkle, James L.

doi:10.15585/mmwr.mm6845e2

Cited by 182 publications

(150 citation statements)

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“…In this study, we investigated the chemical constituents commonly found in e-cig vaping patient-provided counterfeit cartridges, CBD-cartridges, and medical cartridges. The presence of harmful compounds, such as MCT oil, VEA, and other lipids in THC-containing cartridges has been identified by the FDA/CDC (Blount et al 2019a). At present, VEA has been linked as the causative agent based on bronchoalveolar lavage fluid (BALF) analyses in patients with EVALI (Blount et al 2019b).…”

Section: Discussionmentioning

confidence: 99%

Chemical constituents involved in e-cigarette, or vaping product use-associated lung injury (EVALI)

Muthumalage

Friedman

McGraw

et al. 2020

Preprint

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AbstractBackgroundThe Centers for Disease Control (CDC) declared e-cigarette (e-cig), or vaping product use-associated lung injury (EVALI) a national outbreak due to the high incidence of emergency department admissions and deaths. Investigators have identified vitamin E acetate (VEA) as the plausible cause for EVALI, based on compounds found in bronchoalveolar lavage fluid.ObjectivesWe defined the chemical constituents present in e-cig cartridges associated with EVALI and compared constituents to medical-grade and cannabidiol (CBD) containing cartridges.MethodsWe measured chemicals and elemental metals in e-liquid and vapor phases of e-cig counterfeit cartridges by Gas Chromatography (GC) and Mass Spectrometry (MS), EPA method TO-15 by GCMS, and ICP-MS analysis.ResultsWe have identified chemical constituents in e-cig vaping tetrahydrocannabinol (THC)-containing counterfeit cartridges compared to medical-grade and cannabidiol (CBD) containing cartridges. Apart from VEA and THC, other potential toxicants correlated with EVALI included solvent-derived hydrocarbons, silicon conjugated compounds, various terpenes, pesticides/plasticizers/polycaprolactones, and metals. These chemicals are known to cause symptoms, such as cough, shortness of breath or chest pain, nausea, vomiting or diarrhea, fatigue, fever, or weight loss, all symptoms presenting in patients with EVALI.ConclusionThis study provides insights into understanding the chemical-induced disease mechanism of acute lung injury.

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Section: Discussionmentioning

confidence: 99%

Chemical constituents involved in e-cigarette, or vaping product use-associated lung injury (EVALI)

Muthumalage

Friedman

McGraw

et al. 2020

Preprint

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“…Currently, the prime suspect molecule in EVALI is vitamin E, which has been identified in many e-liquids and bronchoalveolar lavage (BAL) samples from affected individuals (19). Little is known about the nondermatologic and nongastrointestinal ingestion effects of vitamin E. It is possible that the inhalation of this large molecule leads to direct cytotoxicity of particular lung cell types, versus an attempted clearance of this molecule by alveolar macrophages that leads to accumulation within the vacuoles due to an inability of these cells to break it down, followed by macrophage cell death or promotion of a proinflammatory macrophage phenotype that drives ALI ( Figure 1B).…”

Section: Vitamin E As a Potential Culpritmentioning

confidence: 99%

What are the mechanisms underlying vaping-induced lung injury?

Alexander

Bellinghausen²,

Eakin

2020

Journal of Clinical Investigation

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“…Clusters of e-cigarette or vaping product use-associated lung injury cases (Layden et al, 2019;Lewis et al, 2019;Siegel et al, 2019;Dicpinigaitis et al, 2020) have been widely reported throughout the USA, but not in Europe. This has been the subject of a number of public health reports and recommendations in the USA (Blount et al, 2019;Lewis et al, 2019;Siegel et al, 2019). A variety of other pulmonary conditions, apparently associated with e-cigarette use, has appeared, sporadically, in a small number of case reports ( Table 3).…”

Section: Lung Disease and E-cigarettesmentioning

confidence: 99%

“…Furthermore, the typical changes of lipoid pneumonia are not generally seen on computed tomography (Henry et al, 2019). E-cigarette or vaping product use-associated lung injury had proved fatal in 39 (2%) of a total of 2051 cases by November 2019 (Blount et al, 2019) and in 57 out of 2355 cases by December 2019 (Ellington et al, 2020). Cases, emergency room visits and hospitalisations have all declined from a peak in September 2019 (Hartnett et al, 2020;Krishnasamy et al, 2020).…”

Section: Clinical Featuresmentioning

confidence: 99%

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E-cigarette or vaping product use-associated lung injury

Ind

2020

Br J Hosp Med

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E-cigarette or vaping product use-associated lung injury is a recently recognised, acute pulmonary syndrome which has been reported (particularly from June to October 2019) throughout the USA, but not in Europe (although one probable case, in the UK, has been reported; Medicines and Healthcare products Regulatory Agency, 2020 ). It presents acutely, most often in young men, as severe pulmonary consolidation, usually with respiratory failure. The mortality is around 2%. The cause(s) are unknown, but it is associated with vaping, particularly using unlicensed cannabis-containing products with tetrahydrocannabinol. Vitamin E acetate, often present in tetrahydrocannabinol-containing vape products as a solvent, has been implicated, as it has been identified in the bronchoalveolar lavage fluid of patients with e-cigarette or vaping product use-associated lung injury. This article reviews the recent literature, including clinical features, presentation and investigations, and possible mechanisms, in the context of vaping practices in the USA and the UK.

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Evaluation of Bronchoalveolar Lavage Fluid from Patients in an Outbreak of E-cigarette, or Vaping, Product Use–Associated Lung Injury — 10 States, August–October 2019

Cited by 182 publications

References 5 publications

Chemical constituents involved in e-cigarette, or vaping product use-associated lung injury (EVALI)

Chemical constituents involved in e-cigarette, or vaping product use-associated lung injury (EVALI)

What are the mechanisms underlying vaping-induced lung injury?

E-cigarette or vaping product use-associated lung injury

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