A 16-year-old boy became critical after vaping caused a potentially life-threatening lung inflammation. The trigger for the condition is likely to have been an "exaggerated immune response" to one of the chemicals found in e-cigarette fluid, say doctors from Nottingham University Hospitals NHS Trust, UK, who treated the teenager with respiratory failure linked to vaping.
"When doctors, who look after children and young people, are faced with someone with a very severe respiratory illness, they should bear in mind vaping as one of the causes," Dr Jayesh Mahendra Bhatt, pediatric respiratory medicine, Nottingham Children's Hospitals NHS Trust, told MEA WorldWide (MEAWW).
The team of doctors say the boy had a case of hypersensitivity pneumonitis, a condition in which the air sacs and airways in the lungs become severely inflamed. The boy was initially suspected of having asthma, which was thought to have worsened.
"We report a case of hypersensitivity pneumonitis (HP) in a young person secondary to vaping. This previously well young person presented with a catastrophic respiratory illness. For such to be the very first presentation of asthma would be virtually unheard of. Our patient fulfills diagnostic criteria for hypersensitivity pneumonitis secondary to e-cigarettes," say the researchers in a short report, which has been published in the Archives of Disease in Childhood.
The report comes even as the US Centers for Disease Control and Prevention (CDC) recently identified vitamin E acetate as the cause behind lung injury outbreaks in the US.
As of November 5, 2019, 2,051 cases of e-cigarette or vaping product use associated lung injury (EVALI) have been reported to CDC, and 39 deaths have been confirmed.
Hypersensitivity pneumonitis is a rare immune disorder in which the lungs become inflamed as a reaction to substances such as inhaled dust, fungus or chemicals.
According to the National Heart, Lung, and Blood Institute (NHLBI), "It occurs in some people after they breathe in certain substances they encounter in the environment. These substances trigger their immune systems, causing short- or long-term inflammation, especially in a part of the lungs called the interstitium. This inflammation makes it harder for the lungs to function properly and may even permanently damage the lungs. If the condition goes untreated or is not well controlled over time, the chronic inflammation can cause irreversible scarring of the lungs that may severely impair their ability to function."
The researchers report that the previously healthy boy - who had not been diagnosed with asthma before - was brought to the emergency department with a seven-day history of fever, cough, and increasing difficulty breathing. Oral antibiotics and asthma reliever inhaler had failed to alleviate any of these symptoms.
Once admitted to the hospital, his condition deteriorated rapidly, and he developed respiratory failure, which required external assistance for his heart and lungs to work properly - known as extracorporeal membrane oxygenation (ECMO). The patient was also given intravenous antibiotics and steroids.
"There was no previous confirmed diagnosis of asthma, and he was not on any regular controller treatment with inhaled corticosteroids. He deteriorated rapidly and required non-invasive, conventional and then high-frequency oscillation ventilation and finally transferred for ECMO because of intractable respiratory failure," say the researchers.
According to the doctors, his condition had become critical after ten days. He developed severe muscle weakness (myopathy) as a result of his critical illness and steroid treatment, which required lengthy rehabilitation.
During his recovery, questioning revealed that he had recently started to use e-cigarettes fairly frequently, using two different liquids, purchased over the counter. The teenager said that at some point, he had used both the liquids in question. He was, however, unable to recollect the exact sequence of use and in particular, which one he had used immediately before becoming unwell.
"The listed ingredients of both the liquids were identical except for the un-named flavorings. He had smoked cannabis a year previously, but not recently. He had no recent bird or farm animal exposure or any recent travel," says the report.
The experts say his lung scans and biopsy samples were consistent with hypersensitivity pneumonitis. He was discharged home 35 days after admission with a plan to slowly taper oral steroids. This led to worsening respiratory status, and he returned to the emergency department on one occasion and was admitted on another requiring intensive treatment for respiratory distress and wheeze.
"He was categorical that he had not used any more e-cigarettes, and there were no other obvious triggers in the environment; however, we did not specifically test him for any respiratory viruses, and the clinical worsening was attributed to a too rapid taper of steroids," the team reports.
Nearly two months after he had first been admitted, he still had symptoms. When the doctors tested his skin reactivity with a tiny amount of vaping fluid, he got worse. They subsequently took blood samples and analyzed both vaping fluids to see if there were any possible chemical triggers.
"The boy seemed to have more antibodies to one of the two liquids, raising the possibility that this might have been the source of his reaction," says the report.
After 14 months, his symptoms cleared up, and the condition of his lungs returned to normal, reports the team.
According to the team, there are two lessons here: the first is always to consider a reaction to e-cigarettes in someone presenting with an atypical respiratory illness. The second, says the team, is that people, who consider e-cigarettes as "much safer than tobacco", should do so at their own risk.
"Flavoured e-cigarettes liquids contain airway irritants and toxicants such as propylene glycol (PG), vegetable glycerine (VG), and many different flavoring chemicals that have been implicated in the pathogenesis and worsening of lung diseases and that likely induce respiratory effects not seen in tobacco smokers. Thermal decomposition of PG and VG, the base constituents of e-liquids, produces reactive carbonyls, including acrolein, formaldehyde, and acetaldehyde, which have known respiratory toxicities," says the team.
"It is possible that the pulmonary manifestations associated with vaping represent a range of disease processes. What is important, however, is that clinicians should consider the possibility of pulmonary disease associated with vaping when patients report recent use, especially when other causes are not identified as the recent epidemic highlights," cautions the team.