Lung Biopsy Findings in Severe Pulmonary Illness Associated With E-Cigarette Use (Vaping)

A Report of Eight Cases

Sanjay Mukhopadhyay, MD; Mitra Mehrad, MD; Pedro Dammert, MD; Andrea V. Arrossi, MD; Rakesh Sarda, MD; David S. Brenner, MD; Fabien Maldonado, MD; Humberto Choi, MD; Michael Ghobrial, MD


Am J Clin Pathol. 2019;153(1):30-39. 

In This Article

Abstract and Introduction


Objectives: The aim of this report is to describe the lung biopsy findings in vaping-associated pulmonary illness.

Methods: Lung biopsies from eight patients with vaping-associated pulmonary illness were reviewed.

Results: The biopsies were from eight men (aged 19–61 years) with respiratory symptoms following e-cigarette use (vaping). Workup for infection was negative in all cases, and there was no evidence for other etiologies. Imaging showed diffuse bilateral ground-glass opacities in all patients. Most recovered with corticosteroid therapy, while one died. Lung biopsies (seven transbronchial, one surgical) showed acute lung injury, including organizing pneumonia and/or diffuse alveolar damage. Common features were fibroblast plugs, hyaline membranes, fibrinous exudates, type 2 pneumocyte hyperplasia, and interstitial organization. Some cases featured a sparse interstitial chronic inflammatory infiltrate. Although macrophages were present within the airspaces in all cases, this feature was not prominent, and findings typical of exogenous lipoid pneumonia were absent.

Conclusions: The histopathology of acute pulmonary illness related to e-cigarette use (vaping) is characterized by acute lung injury patterns, supporting the contention that vaping can cause severe lung damage.


"Vaping" refers to inhalation of the aerosol produced by electronic cigarettes (e-cigarettes, or electronic vaporizers). This aerosol is generated by heating a liquid that usually contains nicotine, flavorings, and other chemicals.[1] E-cigarettes can also be used to deliver marijuana and other drugs. A variation on this theme is "dabbing," which involves inhalation of an aerosol formed by superheating substances that contain high concentrations of tetrahydrocannabinol (THC) and other plant compounds such as cannabidiol. In the recent past, lung disease related to vaping has emerged as a public health issue in the United States, generating considerable attention in the national news media.[2] A recent report in the New England Journal of Medicine described the clinical features of a series of 53 patients from Illinois and Wisconsin with vaping-related pulmonary illness.[3] This report was a major addition to the literature documenting a link between vaping and lung disease. At the time of this writing (September 2019), 530 possible cases of acute lung injury potentially associated with vaping have been reported from 38 states.[1,4] The Centers for Disease Control and Prevention (CDC) has released interim guidelines on case definitions (discussed in detail in the Materials and Methods section).[4]

Despite the intense spotlight on vaping, the pathologic findings of vaping-related lung disease have not been adequately described. A few reports have appended labels to the lung injury patterns observed in these patients based on imaging and/or bronchoalveolar lavage (BAL) findings, but biopsy findings remain largely unknown.[1,5–7] The aim of this report is to describe and illustrate the histopathologic features of lung disease attributable to vaping.