Giant cell interstitial pneumonia secondary to cobalt exposure from e-cigarette use

Abstract

The spectrum of pulmonary disease caused by e-cigarette use is currently emerging and appears to be multifaceted [1]. We describe a patient who developed pathologically documented giant cell interstitial pneumonia following regular use of an e-cigarette. This disorder has been termed hard metal pneumoconiosis, or cobalt lung, due to its close association with exposure to hard metal (cemented tungsten carbide with cobalt) [2]. Analysis of the device's e-liquid revealed significant levels of cobalt, supporting a diagnosis of giant cell interstitial pneumonia associated with inhaled cobalt from regular e-cigarette use.A 49-year-old previously healthy Caucasian female presented with progressive shortness of breath on exertion. She had a non-productive cough and wheezing. She denied any other symptoms. She had recently been given a diagnosis of asthma following an adverse reaction to ketorolac injection for low back pain. At that time, she was told it could be related to her environment. Home medications included daily montelukast 10 mg tablet and albuterol inhaler p.r.n. She had recently worked as a dog trainer, but stopped due to dyspnoea. She had a remote history of smoking cigarettes in her teens and twenties. She had been using a marijuana e-cigarette (ZenPen personal vaporiser) for 6 months.Physical examination showed a well-nourished woman with blood pressure 147/88 mmHg, heart rate 73 bpm, respiratory rate 18 bpm, and oxygen saturation 96% on room air. During a walk test in clinic she desaturated to 87% on room air after 2 min, with a heart rate of 114 bpm and respiratory rate of 25 bpm. Auscultation of her lungs revealed inspiratory crackles at the bases bilaterally. Pulmonary function tests showed moderately severe restriction with a severe diffusion defect: forced vital capacity (FVC) 1.58 L (51% predicted), forced expiratory volume in 1 s (FEV 1 ) 1.28 L (50% predicted), FEV 1 /FVC 81%, total lung capacity (TLC) 2.67 L (56% predicted), diffusing capacity of the lung for carbon monoxide (D LCO ) 7.7 mL•min −1 •mmHg −1 (27% predicted) and transfer coefficient of the lung for carbon monoxide (K CO ) 4.17 mL•min −1 •mmHg −1 •L −1 (99% predicted). Computed tomography (CT) scan of the chest showed bilateral ground glass opacity and ill-defined nodules predominating in the centrilobular regions with sparing of the subpleural lung (figure 1a and b). There was no reticulation, traction bronchiectasis or honeycombing. She underwent a surgical lung biopsy for diagnosis.Standard haematoxylin and eosin-stained histological sections from the surgical lung biopsy were reviewed by light microscopy.The e-liquid from the ZenPen micro-vaporiser belonging to the patient was analysed using inductively coupled plasma mass spectrometry (ICP-MS) as described previously by HESS et al. [3]. Two aliquots from the same sample were analysed, and the mean metal concentration of the two replicates was calculated. The metals analysed were aluminium, chromium, manganese, cobalt, nickel, arsenic, molybdenum, tungsten, cadmium and lead.Glas...

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