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An early mysterious case of acute lung disease indicated vaping



p. John E. Parker was working at a hospital in West Virginia in 2015 when a 31-year-old patient was admitted with acute respiratory problems. A team of doctors eventually suspected her mysterious case of lipoid pneumonia may be related to vaping, and we were not sure they had seen anything like this before. They were intrigued enough to publish a case report – a type of medical paper for unusual or provocative patient findings. Such reports can serve as a call to the medical community to be on the alert, although they sometimes raise more questions than answer.

This summer, almost four years later, federal officials have launched an investigation into a national vaping center for severe pulmonary disease that has affected more than 1

50 patients in 16 countries. In an interview with Parker, a professor of pulmonary critical care and sleep medicine at West Virginia University, he described what happened.

Question: Can you describe the patient's symptoms upon arrival?

We will treat them as classic for what comes to be called lung disease. She was very, very breathless and coughing and we, of course, were very worried that there might be pneumonia or some other acute respiratory illness. And then she was so sick that she had to be intubated.

Q: What happens next in such cases?

We are looking for things like [hemorrhage] or active infection. And then for macrophages containing lipids. And then we usually start some antibiotics [and a] low-dose steroids and then support the patient with ventilator and oxygen and nutrition. And then just wait and see if any other culture comes back to prove something different than what you might think.

At first, we just felt it was an unusual case and may not be a common viral or bacterial infection.

Q: How did you find out the cause of her lipoid pneumonia is electronic cigarettes?

This is an exclusion diagnosis. We excluded others [options] and this became the most probable cause.

We were convinced enough that the case was presented this year at the annual meeting of the American College of Thoracic Doctors.

Q: After you have understood the cause may be electronic cigarettes, have you contacted the Centers for Disease Control and Prevention or the Food and Drug Administration or any other regulatory agency to inform them?

We didn't. At that time, we felt that placement in the medical literature was appropriate. And if other cases were presented from other parts of the country, then we would have more than a grouping of findings that might require research agencies [getting a] to have a better understanding [about] of the cause of the disease.

Q:

In 2015, the FDA was still regulating cigarettes, but I don't think the government has yet to decide who will regulate vaping products. So I'm sure it wasn't clear who to call.

Q: So you or your team think it's a one-off event when you witness it?

We really felt that this was not going to be a one-off event and that this is what we usually call a public health "healthy" health event … that this is an example of a respiratory illness that can be caused by this exposure and that probably not the first case ever seen nor will it be the last.

Q: Was it the first case you saw at your institution?

To our knowledge, this was our first case, but we are modest enough clinicians to realize that we may have missed some other cases that we have interpreted [as] viral pneumonia or bacterial pneumonia.

Q: Have you seen more cases since then?

I know we have seen a case [of alveolar hemorrhage syndrome] that we published, and in interviewing some colleagues we think that we may have also seen [cases of] cryptogenic organizing pneumonia, as well as lipoid pneumonia nia and acute eosinophilic pneumonia. Yes, we have certainly seen at least four forms of vaping lung disease.

Q: If your team saw this in 2015, is it possible that this has happened in the four years since and people just do it

I really have every reason to think that we are not the first to do it they see in any way.

And I don't think we were even the first to report it. I think there were some clusters in Wisconsin and some other places in the US. I also know that the Japanese showed great interest. They probably have four or five reports at least in the medical literature about lung-related lung injuries.

Question: Do you have a theory as to what may be the cause of lipoid pneumonia? Do you think there may be some chemicals that are annoying?

We need a strong multidisciplinary team to understand the true etiology and cause of lung damage by inhalation. I think there can be any number of components in the mixes. In general, the lungs do not like butter, and probably the most specific agent recently tested is diacetyl, which has been tested for pulmonary popcorn disease.

Q: Have these types of cases changed as you approach patients?

Yes, we are looking very vaping history very carefully. … I think it's pretty important to understand if they can use inhalants or vaping that can present new toxic substances to the lungs.

Q: Will these diseases have long-term health effects?

Inhalation injury can cause acute lung injury, which is life-threatening and that anyone can survive from and have no long-term effects [condition]. But there is also the possibility that long-term use [e-cigarette] may cause more insidious or chronic illnesses, from which complete recovery may not be obtained.


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