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Schier JG, Meiman JG, Layden J, Mikosz CA, VanFrank B, King BA, Salvatore PP, Weissman DN, Thomas J, Melstrom PC, Baldwin GT, Parker EM, Courtney-Long EA, Krishnasamy VP, Pickens CM, Evans ME, Tsay SV, Powell KM, Kiernan EA, Marynak KL, Adjemian J, Holton K, Armour BS, England LJ, Briss PA, Houry D, Hacker KA, Reagan-Steiner S, Zaki S, Meaney-Delman D, Navon L. MMWR Morb. Mortal. Wkly. Rep. 2019; 68(36).


(Copyright © 2019, (in public domain), Publisher U.S. Centers for Disease Control and Prevention)






What is already known about this topic?

Twenty-five states have reported more than 200 possible cases of severe pulmonary disease associated with the use of electronic cigarettes (e-cigarettes).

What is added by this report?

Based on available information, the disease is likely caused by an unknown chemical exposure; no single product or substance is conclusively linked to the disease.

What are the implications for public health practice?

Until a definitive cause is known, persons should consider not using e-cigarettes. Those who use e-cigarettes should seek medical attention for any health concerns. Clinicians should report possible cases to their local or state health department.

As of August 27, 2019, 215 possible cases of severe pulmonary disease associated with the use of electronic cigarette (e-cigarette) products (e.g., devices, liquids, refill pods, and cartridges) had been reported to CDC by 25 state health departments. E-cigarettes are devices that produce an aerosol by heating a liquid containing various chemicals, including nicotine, flavorings, and other additives (e.g., propellants, solvents, and oils). Users inhale the aerosol, including any additives, into their lungs. Aerosols produced by e-cigarettes can contain harmful or potentially harmful substances, including heavy metals such as lead, volatile organic compounds, ultrafine particles, cancer-causing chemicals, or other agents such as chemicals used for cleaning the device (1). E-cigarettes also can be used to deliver tetrahydrocannabinol (THC), the principal psychoactive component of cannabis, or other drugs; for example, "dabbing" involves superheating substances that contain high concentrations of THC and other plant compounds (e.g., cannabidiol) with the intent of inhaling the aerosol. E-cigarette users could potentially add other substances to the devices. This report summarizes available information and provides interim case definitions and guidance for reporting possible cases of severe pulmonary disease. The guidance in this report reflects data available as of September 6, 2019; guidance will be updated as additional information becomes available.

Preliminary reports from state health department investigations, a published case series of patients in Illinois and Wisconsin (2), and three other published case series (3-5), describe clinical features of pulmonary illness associated with e-cigarette product use. According to these reports, the onset of respiratory findings, which might include a nonproductive cough, pleuritic chest pain, or shortness of breath, appears to occur over several days to several weeks before hospitalization. Systemic findings might include tachycardia, fever, chills, or fatigue; reported gastrointestinal findings, which have preceded respiratory findings in some cases, have included nausea, vomiting, abdominal pain, and diarrhea. Most identified patients have been hospitalized with hypoxemia, which, in some cases, has progressed to acute or subacute respiratory failure. Patients have required respiratory support therapies ranging from supplemental oxygen to endotracheal intubation and mechanical ventilation. Many patients initially received a diagnosis of infection and were treated empirically with antibiotics without improvement. In the largest cohort, 53 patients from Illinois and Wisconsin (2), the six-patient case series in Utah (4), and in the five North Carolina patients described in a report in this issue of MMWR (3), many of the patients who were treated with corticosteroids improved. All patients described in these reports to date have had abnormal radiographic findings, including infiltrates on chest radiograph and ground glass opacities on chest computed tomography scan.

All patients have a reported history of e-cigarette product use, and no consistent evidence of an infectious etiology has been discovered. Therefore, the suspected cause is a chemical exposure. The type, extent, and severity of any chemical-related illness might depend on multiple factors including the chemical to which the user was exposed; chemical changes associated with heating, dose, frequency, and duration of exposure; product delivery methods; and behaviors and medical conditions of the user. The specific behaviors and exposures of identified patients have varied. Most have reported a history of using e-cigarette products containing cannabinoids such as THC, some have reported the use of e-cigarette products containing only nicotine, and others have reported using both. No consistent e-cigarette product, substance, or additive has been identified in all cases, nor has any one product or substance been conclusively linked to pulmonary disease in patients.

Health care providers who cared for the five North Carolina patients diagnosed acute exogenous lipoid pneumonia in all patients based on history of e-cigarette use and clinical, radiographic, laboratory, and bronchoscopy findings. Specifically, the authors identified lipids within alveolar macrophages from the three bronchoalveolar lavage (BAL) specimens stained with oil red O. All five patients reported using marijuana oils or concentrates in e-cigarettes, and three also reported using nicotine (3). In a report describing the clinical course and outcomes of six patients from Utah, health care providers described the potential diagnostic utility of identification of lipid-laden macrophages from BAL specimens (4). Among the 53 cases from Illinois and Wisconsin, however, the pathologic findings were heterogeneous. Whereas almost half (24/53) of these patients underwent BAL, seven reports described the use of oil red O stain that identified lipid-laden macrophages (2). Additional pathologic analyses are in progress on specimens from some of these patients (2). The clinical significance of lipid-laden macrophages is currently unclear. It is not known whether the lipid is exogenous (from inhaled material) or endogenous (from altered lipid metabolism). In addition, it is not known whether lipid-laden macrophages are a marker of exposure to e-cigarette aerosol or they are central to the disease process.

CDC is currently coordinating a multistate investigation. Investigations in affected states are focused on describing exposures and the epidemiologic, clinical, laboratory, and behavioral characteristics of cases. In conjunction with a task force from the Council for State and Territorial Epidemiologists and affected states, interim outbreak surveillance case definitions* (Table), data collection tools, and a database to collect relevant patient data have been developed and released. The interim outbreak case definitions will be updated as necessary as additional information becomes available...

Language: en


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