Perspective

Nearly 200 cases of severe pulmonary disease possibly linked to vaping

As of Aug. 23, 193 possible cases of severe respiratory disease associated with use of e-cigarettes, or vaping, including 30 cases in Wisconsin and 22 in Illinois, have been reported in 22 states from June 28 to Aug. 22. One patient in Illinois has died, according to the CDC.

“CDC is currently providing consultations to state health departments about the cluster of pulmonary illnesses possibly related to e-cigarette product use or vaping, primarily among adolescents and young adults. Many states have alerted CDC to possible, but not yet confirmed cases, and investigation into these cases are ongoing. In addition, the FDA is working with CDC and state health officials to gather information on any products or substances used and providing technical and laboratory assistance,” Ileana Arias, PhD, acting deputy director of Non-infectious Diseases at CDC, said during a telebriefing on Aug. 23.

Arias also said the CDC has not identified a specific cause, though available evidence does not suggest that infectious disease is the primary cause of the illness and that all patients have reported e-cigarette use.

Additionally, the agency stated that cases appear similar, but it has not yet been established that they have a common cause or if they are different diseases with similar presentations.

“Right now, states are leading their own epidemiologic investigations, but CDC is actively working with the states to try to harmonize that reporting structure across states and we’re releasing data collection tools as well as a standardized case definition to help states harmonize again their investigations and collect data so that hopefully we can look at this in a more standardized fashion. Those health messaging and data collection tools will be going out this weekend,” Joshua Schier, MD, from the CDC’s Division of Unintentional Injury Prevention, said during the telebriefing.

In a Clinician Outreach and Communication Activity (COCA) Clinical Message issued on Aug. 14, the CDC reported that 15 of the cases in Wisconsin were confirmed using a definition drafted by the state’s Department of Health Services and 15 remain under investigation. Patients’ respiratory symptoms at presentation included cough, shortness of breath and fatigue that worsened over several days or weeks before hospital admission. Some patients also reported fever, chest pain, weight loss, nausea or diarrhea. Notably, chest radiographs showed bilateral opacities and CT chest scans demonstrated diffuse ground-opacities, often with sub-pleural sparing, in these patients, but clinicians have detected no infections. In some cases, patients experienced respiratory failure requiring mechanical ventilation but subsequently improved with treatment with corticosteroids.

Speaking on the cases in Illinois, Jennifer Layden, MD, PhD, chief medical officer and state epidemiologist at the Illinois Department of Public Health, reported that, in addition to the 22 suspected cases across the state, another 12 are under investigation. She added that one adult who had been hospitalized with severe unexplained respiratory illness after reported vaping or e-cigarette use died on Aug. 22. She offered no further details about the individual case at this time and stated that the Illinois Department of Health is working with local health departments, FDA and CDC to learn more.

Possible causes

Although a specific cause has not yet been identified, all patients reported vaping in the weeks and months before hospital admission, with many also acknowledging recent use of tetrahydrocannabinol (THC)-containing products. However, officials have not determined that any product is linked to this clinical syndrome and no specific product has been identified in all cases.

In a statement, the Wisconsin Department of Health Services said it is continuing to work with the Wisconsin State Lab of Hygiene and the FDA to investigate the possible cause of these illnesses by testing patient specimens and vaping products.

As of Aug. 21, 153 possible cases of severe respiratory disease associated with use of e-cigarettes, or vaping, including 30 cases in Wisconsin, have been reported in 16 states from June 28 to Aug. 20, according to the CDC.

Source: Shutterstock

Other states, including Illinois, have followed suit.

“Our agency is committed to continuing to work very closely with both CDC and state health officials and working as quickly as possible to gather more information about all of these cases. In particular, FDA has been and will continue to provide technical and laboratory assistance to help identify any products or substances used in these cases. Our Office of Emergency operations is coordinating our activities and the agency is participating in regular meetings with CDC and all state health officials,” Mitch Zeller, JD, director of Center for Tobacco Products at the FDA, said during the telebriefing.

“FDA has also received some product samples from a number of states and we’re starting to analyze those samples for its contents to see whether they contain nicotine, whether they contain substances such as THC or other cannabinoids or other chemicals and ingredients. Whatever results we get from our testing will be shared with the respective states that submitted them to aid in their ongoing investigations. FDA is also working to investigate the brands and types of vaping products and devices, whether any of them are products that would fall within FDA’s regulatory authority as well as where they were obtained. We don’t have any specific information to share at this time; however, the agency will continue to communicate with the public about this issue,” he said.

Also, in a memo issued by the Wisconsin Department of Health Services, officials initially identified the cluster of cases as primarily occurring in adolescents and young adults. However, more recent reports show that cases of this respiratory disease — confirmed or suspected — have occurred in people up to age 53 years, according to the COCA Clinical Message.

“We are continuing to interview patients so we can identify a possible cause,” Andrea Palm, Wisconsin Department of Health Services Secretary-designee, said in an Aug. 8 press release. “All patients reported vaping prior to their hospitalization, but we don’t know all the products they used at this time. The products used could include a number of substances, including nicotine, THC, synthetic cannabinoids or a combination of these.”

The CDC notes, however, that the etiology of the illness remains unclear and epidemiological investigations are ongoing.

Other states

In addition to Wisconsin and Illinois, states including California, Connecticut, Florida, Indiana, Iowa, Minnesota, Michigan, North Carolina, New Jersey, New Mexico, New York, Pennsylvania, Texas and Utah, among others, also have identified possible cases of similar illness and several states have issued alerts to health care providers to look out for patients with similar symptoms and a history of e-cigarette use, according to the CDC.

"While many people consider vaping to be a less dangerous alternative to smoking cigarettes, it is not risk-free," Howard Zucker, MD, JD, New York State Health Commissioner, which is investigating 11 reported cases of pulmonary disease in people using e-cigarette products, said in a statement. "These latest reports of pulmonary disease in people using vaping products in New York and other states are proof that more study is needed on the long-term health effects of these products."

Minnesota has also reported four cases of severe lung disease that are potentially associated with vaping, according to a news release from the state’s Department of Health. Although officials have again not identified a specific cause, patients have similar symptoms as those from other states and have reported e-cigarette use before hospital admission.

“There are still many unanswered questions, but the health harms emerging from the current epidemic of youth vaping in Minnesota continue to increase,” Ruth Lynfield, MD, state epidemiologist and the medical director of the Minnesota Department of Health, said in a news release from the state’s Department of Health. “We are encouraging providers and parents to be on the look-out for vaping as a cause for unexplained breathing problems and lung injury and disease.”

Healio Pulmonology is closely monitoring this story and will update the article as new information becomes available. – by Melissa Foster

Editor’s note: This article has been updated to indicate that 15 cases, not 30, in Wisconsin have been confirmed. The editors regret the error. This article was updated on Aug. 21 to include new information from the CDC on the number of cases and states affected. This article was updated on Aug. 23 to reflect new information provided during a CDC telebriefing.

As of Aug. 23, 193 possible cases of severe respiratory disease associated with use of e-cigarettes, or vaping, including 30 cases in Wisconsin and 22 in Illinois, have been reported in 22 states from June 28 to Aug. 22. One patient in Illinois has died, according to the CDC.

“CDC is currently providing consultations to state health departments about the cluster of pulmonary illnesses possibly related to e-cigarette product use or vaping, primarily among adolescents and young adults. Many states have alerted CDC to possible, but not yet confirmed cases, and investigation into these cases are ongoing. In addition, the FDA is working with CDC and state health officials to gather information on any products or substances used and providing technical and laboratory assistance,” Ileana Arias, PhD, acting deputy director of Non-infectious Diseases at CDC, said during a telebriefing on Aug. 23.

Arias also said the CDC has not identified a specific cause, though available evidence does not suggest that infectious disease is the primary cause of the illness and that all patients have reported e-cigarette use.

Additionally, the agency stated that cases appear similar, but it has not yet been established that they have a common cause or if they are different diseases with similar presentations.

“Right now, states are leading their own epidemiologic investigations, but CDC is actively working with the states to try to harmonize that reporting structure across states and we’re releasing data collection tools as well as a standardized case definition to help states harmonize again their investigations and collect data so that hopefully we can look at this in a more standardized fashion. Those health messaging and data collection tools will be going out this weekend,” Joshua Schier, MD, from the CDC’s Division of Unintentional Injury Prevention, said during the telebriefing.

In a Clinician Outreach and Communication Activity (COCA) Clinical Message issued on Aug. 14, the CDC reported that 15 of the cases in Wisconsin were confirmed using a definition drafted by the state’s Department of Health Services and 15 remain under investigation. Patients’ respiratory symptoms at presentation included cough, shortness of breath and fatigue that worsened over several days or weeks before hospital admission. Some patients also reported fever, chest pain, weight loss, nausea or diarrhea. Notably, chest radiographs showed bilateral opacities and CT chest scans demonstrated diffuse ground-opacities, often with sub-pleural sparing, in these patients, but clinicians have detected no infections. In some cases, patients experienced respiratory failure requiring mechanical ventilation but subsequently improved with treatment with corticosteroids.

Speaking on the cases in Illinois, Jennifer Layden, MD, PhD, chief medical officer and state epidemiologist at the Illinois Department of Public Health, reported that, in addition to the 22 suspected cases across the state, another 12 are under investigation. She added that one adult who had been hospitalized with severe unexplained respiratory illness after reported vaping or e-cigarette use died on Aug. 22. She offered no further details about the individual case at this time and stated that the Illinois Department of Health is working with local health departments, FDA and CDC to learn more.

Possible causes

Although a specific cause has not yet been identified, all patients reported vaping in the weeks and months before hospital admission, with many also acknowledging recent use of tetrahydrocannabinol (THC)-containing products. However, officials have not determined that any product is linked to this clinical syndrome and no specific product has been identified in all cases.

In a statement, the Wisconsin Department of Health Services said it is continuing to work with the Wisconsin State Lab of Hygiene and the FDA to investigate the possible cause of these illnesses by testing patient specimens and vaping products.

As of Aug. 21, 153 possible cases of severe respiratory disease associated with use of e-cigarettes, or vaping, including 30 cases in Wisconsin, have been reported in 16 states from June 28 to Aug. 20, according to the CDC.

Source: Shutterstock

Other states, including Illinois, have followed suit.

“Our agency is committed to continuing to work very closely with both CDC and state health officials and working as quickly as possible to gather more information about all of these cases. In particular, FDA has been and will continue to provide technical and laboratory assistance to help identify any products or substances used in these cases. Our Office of Emergency operations is coordinating our activities and the agency is participating in regular meetings with CDC and all state health officials,” Mitch Zeller, JD, director of Center for Tobacco Products at the FDA, said during the telebriefing.

“FDA has also received some product samples from a number of states and we’re starting to analyze those samples for its contents to see whether they contain nicotine, whether they contain substances such as THC or other cannabinoids or other chemicals and ingredients. Whatever results we get from our testing will be shared with the respective states that submitted them to aid in their ongoing investigations. FDA is also working to investigate the brands and types of vaping products and devices, whether any of them are products that would fall within FDA’s regulatory authority as well as where they were obtained. We don’t have any specific information to share at this time; however, the agency will continue to communicate with the public about this issue,” he said.

Also, in a memo issued by the Wisconsin Department of Health Services, officials initially identified the cluster of cases as primarily occurring in adolescents and young adults. However, more recent reports show that cases of this respiratory disease — confirmed or suspected — have occurred in people up to age 53 years, according to the COCA Clinical Message.

“We are continuing to interview patients so we can identify a possible cause,” Andrea Palm, Wisconsin Department of Health Services Secretary-designee, said in an Aug. 8 press release. “All patients reported vaping prior to their hospitalization, but we don’t know all the products they used at this time. The products used could include a number of substances, including nicotine, THC, synthetic cannabinoids or a combination of these.”

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The CDC notes, however, that the etiology of the illness remains unclear and epidemiological investigations are ongoing.

Other states

In addition to Wisconsin and Illinois, states including California, Connecticut, Florida, Indiana, Iowa, Minnesota, Michigan, North Carolina, New Jersey, New Mexico, New York, Pennsylvania, Texas and Utah, among others, also have identified possible cases of similar illness and several states have issued alerts to health care providers to look out for patients with similar symptoms and a history of e-cigarette use, according to the CDC.

"While many people consider vaping to be a less dangerous alternative to smoking cigarettes, it is not risk-free," Howard Zucker, MD, JD, New York State Health Commissioner, which is investigating 11 reported cases of pulmonary disease in people using e-cigarette products, said in a statement. "These latest reports of pulmonary disease in people using vaping products in New York and other states are proof that more study is needed on the long-term health effects of these products."

Minnesota has also reported four cases of severe lung disease that are potentially associated with vaping, according to a news release from the state’s Department of Health. Although officials have again not identified a specific cause, patients have similar symptoms as those from other states and have reported e-cigarette use before hospital admission.

“There are still many unanswered questions, but the health harms emerging from the current epidemic of youth vaping in Minnesota continue to increase,” Ruth Lynfield, MD, state epidemiologist and the medical director of the Minnesota Department of Health, said in a news release from the state’s Department of Health. “We are encouraging providers and parents to be on the look-out for vaping as a cause for unexplained breathing problems and lung injury and disease.”

Healio Pulmonology is closely monitoring this story and will update the article as new information becomes available. – by Melissa Foster

Editor’s note: This article has been updated to indicate that 15 cases, not 30, in Wisconsin have been confirmed. The editors regret the error. This article was updated on Aug. 21 to include new information from the CDC on the number of cases and states affected. This article was updated on Aug. 23 to reflect new information provided during a CDC telebriefing.

    Perspective
    Humberto Choi

    Humberto Choi

    The major concern with these lung diseases related to vaping is that there is a spectrum of symptoms that can range from very mild cough in a patient with a normal X-ray and CT scan to more severe cases of cough, shortness of breath and fatigue with abnormal imaging. It is also particularly worrisome that the disease was severe enough to cause respiratory failure requiring mechanical ventilation in some patients.

    Currently, we do not have any signature or hallmark that can be seen in a blood test or even on a lung biopsy indicating that this lung disease is specific to vaping, but we normally look for possible causes of these symptoms, such as infections or exposures, and currently, the exposure that we are seeing frequently is vaping.

    At present, we are not yet sure through what mechanism vaping may influence development of this severe lung disease. It could be that the chemicals used in the liquids combined with the high temperatures that cause the vapor could be problematic. However, in many cases, patients reported combined use with other inhalation substances, most commonly marijuana. Perhaps there is a synergistic effect occurring that may explain the disease.

    Although vaping-related respiratory illness is receiving significant attention now due to the number of cases and their severity, I think we have probably seen more mild cases in young adults who, for instance, only present with mild cough, which can have many causes, such as viral infection. These more severe cases have raised our level of suspicion and we can now consider vaping as a possible cause for these other milder cases.

    Unfortunately, this whole area is so new that we do not even have an ICD code for vaping-related lung diseases, so it is difficult to track, but suspected cases should be reported to the CDC. Hopefully, we will identify more confirmed cases so we can better characterize the disease and determine how best to treat these patients.

    For now, I recommend that clinicians do their due diligence when evaluating a patient who presents with these types of symptoms. Conduct all of the necessary tests, including chest X-rays, CT scans and blood test; perform a good physical exam; and obtain a comprehensive patient history to explain the disease and remain aware that vaping could be a potential cause.

    • Humberto Choi, MD
    • Pulmonologist and Critical Care Specialist
      Cleveland Clinic

    Disclosures: Choi reports no relevant financial disclosures.