E-cigarette Lung Damage Possible Without Respiratory Symptoms

By Lisa Rapaport

April 27, 2020

(Reuters Health) - Electronic cigarette or vaping product use-associated lung injury (EVALI) can occur even in people who don't have respiratory symptoms, a case study of one teenage patient suggests.

As vaping becomes more common, a growing number of U.S. adolescents are presenting to emergency departments with a constellation of respiratory, gastrointestinal, and constitutional symptoms characteristic of EVALI, researchers note in Pediatrics. The current case study focuses on an adolescent male with many classic symptoms of EVALI but none of the respiratory symptoms that have been reported the majority of EVALI cases.

"It makes sense that any amount of vaping could be harmful to the lungs, but we don't really know what these effects are since we haven't really studied asymptomatic people who vape," said coauthor Dr. Michael Fox of the Nemours/Alfred I. duPont Hospital of Children in Wilmington, Delaware.

"This case report suggests that there may be damage to the lungs before a patient ever develops any symptoms specific to that damage (e.g., cough, trouble breathing, trouble with gas exchange)," Dr. Fox said by email.

The 16-year-old male subject of the case report presented to the emergency department with a 25-pound weight loss over three months of persistent postprandial nausea, decreased appetite, and occasional nonbloody and nonbilious emesis.

The patient reported a 2-year history of daily vaping. He also reported using nicotine-based products multiple times a day and tetrahydrocannabinol-containing cartridges at night over the past few months.

He said he had stopped vaping about two weeks earlier and that he had seen a temporary resolution of his nausea and vomiting as well as improvement in his appetite.

But in the three days before he came to the emergency department, he developed daily fever, headache, nausea, non-bloody and nonbilious emesis, and one episode of non-bloody diarrhea. He said he had not previously experienced symptoms like cough, dyspnea, chest pain, or exertional intolerance.

Results of a urine drug test were positive for marijuana metabolites.

His initial workup was unremarkable for pulmonary pathologies, and throughout his hospital stay he denied respiratory symptoms.

Two days before admission, the patient's primary care provider had obtained lab test results that revealed a complete blood count notable for a white blood cell count of 12 700 cells/μL and 91% neutrophils and a C-reactive protein (CRP) elevated to 29.7 mg/dL, according to the report.

During his stay, a CT scan of his abdomen and pelvis that showed lung pathology characteristic of EVALI, and he was subsequently diagnosed with EVALI.

By the end of his 7-day stay, he reported improved mood; resolution of his nausea, emesis, and fever; and marked improvement in his appetite. This mirrored his improving inflammatory markers and pulmonary function tests.

The current literature includes only two previous reports of patients diagnosed with EVALI and requiring hospital admission but lacking respiratory symptoms, the authors note. Gastrointestinal symptoms, including nausea, vomiting, diarrhea, and abdominal pain are highly prevalent in past reports, however.

Because of the lack of pulmonary complaints, this patient appears to be an atypical EVALI case. It is possible that this is because he came to the hospital sooner in the course of his illness, before respiratory symptoms could develop, researchers acknowledge in Pediatrics.

There are, however, no data on how early intervention might alter the course of EVALI and it’s still not clear what the most effective treatment for the condition may be, the study team notes.

"The take-home message is that vaping is NOT a safe alternative to smoking," Fox said. "They both can cause lung damage, and other problems, both short- and long-term."

The mechanisms and pathways of the sensation of dyspnea associated with vaping are incompletely understood, and can be quite complex, said Dr. David Christiani of the Harvard T.H. Chan School of Public Health and Massachusets General Hospital in Boston.

"The sensation of shortness of breath, or dyspnea, depends on nerves in the lung and chest wall, and their connection with the brain," Dr. Christiani, who wasn't involved in the study, said by email. "There is a lot of individual variability."

"Interestingly, in this case report, the GI symptoms predominate and are out of proportion to the respiratory symptoms, so this patient had accentuated GI symptoms and less than expected shortness of breath," Dr. Christiani added. "But, important to remember, the patient still showed significant signs of lung injury on CT scan and accompanied by low oxygen on walking."

SOURCE: https://bit.ly/3axqIbv Pediatrics, online April 21, 2020.