Getting to the bottom of the vaping mystery lung illness

Scientists chase cause of mysterious vaping illness as death toll rises

Getting to the bottom of the vaping mystery lung illness

The wide variety of vaping cartridges available for purchase has complicated efforts to trace the cause of a mysterious lung disease.Credit: Richard Vogel/AP/Shutterstock

Until a few months ago, pulmonologist Sean Callahan didn’t typically ask his patients if they vaped. He thought that e-cigarettes might help smokers wean themselves off cigarettes, and that the risks of vaping would probably take years to become clear.

The emergence of a mysterious, sometimes lethal, lung injury associated with vaping has changed his mind. Callahan works at the University of Utah Health in Salt Lake City, which has treated about 20 victims of the outbreak. “It was surprising: the overwhelming number of them — and how young they were,” he says.

Researchers and physicians a were caught unprepared by the illness, which has now sickened about 1,300 US vapers and killed 26.

Scientists are scrambling to find out why, and to save other vapers from the same fate. “Everything is rapidly evolving,” says Brandon Larsen, a pulmonary pathologist at the Mayo Clinic in Phoenix, Arizona.

“I could tell you something today and next week it could be totally wrong.”

A paper1 published by Larsen and his colleagues in the New England Journal of Medicine on 2 October undercut a popular theory behind the outbreak — and underscored how far researchers still have to go to pinpoint its cause.

Disease detectives

Many of those sickened in the outbreak had vaped cartridges containing tetrahydrocannabinol (THC) — the active ingredient in marijuana — that was diluted with oily chemicals.

Larsen’s study is the largest analysis to date of lung tissue taken from sickened vapers. The scientists searched for evidence of lipoid pneumonia, a condition that arises when oil enters the lungs.

It is marked by lipid found in lung tissue and also in cells called macrophages, which normally sweep up debris in the lungs. But Larsen and his colleagues did not find substantial lipid droplets in any of their samples from 17 patients.

Instead, their findings point to general lung damage and inflammation caused by exposure to toxic chemicals.

There are reasons to be sceptical of those results, says Kevin Davidson, a pulmonologist at WakeMed, a hospital system based in Raleigh, North Carolina. He says that Larsen looked for signs of disease that would be apparent only if someone had inhaled a large amount of oil all at once, not small amounts over time.

But Larsen’s findings do align with mouse studies2 carried out by Farrah Kheradmand, a pulmonologist at Baylor College of Medicine in Houston, Texas.

Her team found lipids accumulating in the lung macrophages of mice exposed to e-cigarettes. The scientists traced the build-up to the breakdown of pulmonary surfactant, a lipid-rich compound produced by the lungs.

Kheradmand says this suggests that vaping damages cells that line airways and help to maintain surfactant levels.

She is now hoping to repeat her mouse studies using e-cigarette vapour that contains vitamin E acetate, an oily chemical that has been suggested as a cause of the vaping illness. Other researchers are considering similar experiments.

Steven Rowe, a pulmonologist at the University of Alabama, Birmingham, hopes to test suspected culprits using ferrets, to learn how vaping affects ion transport in human lung cells. And Quan Lu, a lung biologist at the Harvard T. H.

Chan School of Public Health in Boston, Massachusetts, is planning an experiment to look at what genes are switched on or off in lung cells taken from vapers. He hopes to get tissue samples from those who have become ill.

But Kheradmand cautions against hoping for quick answers: her initial mouse study took three and a half years to complete.

“Science will win at some point,” says Albert Rizzo, chief medical officer at the American Lung Association in Chicago, Illinois. “But I don’t think it’s going to be as soon as people would .”

Many suspects

More immediately, researchers are scrambling to categorize the chemicals contained in e-cigarettes.

That is no simple task when there are thousands of products available, and a culture of users modifying e-cigarettes and their contents to change characteristics such as flavour or amount of vapour produced.

“This is a tough nut to crack, to be honest,” says Larsen. “And that’s where the research really needs to go: figuring out what the contents are in all of these things.”

The range of chemicals that vapers are exposed to is dazzling, says Mignonne Guy, a biobehavioural researcher at Virginia Commonwealth University in Richmond.

Her laboratory has studied videos and other online sources to learn more about how e-cigarette users are modifying their devices.

They found that vapers are altering everything from how hot their e-cigarettes get to what chemicals are included in vaping cartridges — including, in at least one instance, liquid Viagra.

Online forums have pointed computational epidemiologist Yulin Hswen towards an early-2019 spike in posts about how to make e-cigarette cartridges.

This was soon followed by an increase in posts from users warning about black-market cartridges sold with branding that could mislead the purchaser into thinking they were made by a reputable company.

Hswen, who works at the Harvard School of Public Health in Boston, Massachusetts, plans to look more closely to see whether this spike in homebrew cartridges could have contributed to the outbreak.

Ultimately, researchers might never be able to track down a single cause for the outbreak, says David Christiani, a pulmonologist at Harvard's public-health school.

But even just narrowing it down to a process — such as using oils to dilute THC — could help to squelch the current epidemic and save lives. “We have a very serious epidemic and we absolutely need to get that under control,” he says.

“Then that will allow us to go back to focusing on chronic effects of vaping.”

Nature 574, 303-304 (2019)


THC vape products may be the main culprit in the mysterious lung illness outbreak

Getting to the bottom of the vaping mystery lung illness
Of the 1,080 cases involving vaping-related lung injury, 78 percent reported using THC-containing products, with or without nicotine.

Yui Mok/PA Images via Getty Images

The outbreak of the mysterious vaping-related illness is continuing “at a brisk pace,” with 1,080 cases and 18 deaths across the country, said Centers for Disease Control and Prevention principal deputy director Anne Schuchat on Thursday.

That’s an increase of 275 cases from last week’s report — a combination of new patients getting sick and new reporting of previously-identified patients.

As the cases mount, investigators appear to be getting closer to nailing down one of the main causes of the outbreak of mysterious lung injuries linked with e-cigarettes: vaping products containing THC, the main psychoactive chemical in cannabis.

On Thursday, CDC officials reaffirmed that while they haven’t figured out exactly which chemical or device is making people sick, the majority of the cases in both national and state studies to date appear to involve THC-based vaping products. Many of them are illicit products labeled with brand names such as “Dank Vape.”

According to the latest count, about 78 percent of the patients in cases CDC’s analyzed reported using THC-containing products, with or without nicotine, while 37 percent reported only using THC-containing e-cigarettes.

The new findings are consistent with a published analysis of cases by CDC last week. the 514 national cases the agency analyzed, 77 percent had reported using THC-containing products or both THC and nicotine, while 16 percent reported using only nicotine-containing products.

The CDC also shared more details about the groups hardest hit: more than two-thirds are male, with a median age of 23. Sixty-two percent are ages 18 to 34, and more than half are under the age of 25. Ninety-one percent were hospitalized.

Among the states with the most cases to date: California, Texas, Wisconsin, and Illinois.

Number of cases of lung injury associated with e-cigarette use, or vaping, in the United States, including two territories, so far in 2019. CDC

A separate study, also published in the CDC’s Morbidity and Mortality Weekly Report, focused on patients in Illinois and Wisconsin, and it came to a similar conclusion.

Of the 86 patients interviewed, 87 percent said they’d used products with THC.

The overwhelming majority (96 percent) of the THC products these patients reported using involved pre-packaged, pre-filled cartridges or pods, which they said they did not tinker with.

These products were bought primarily from “informal sources such as friends, family members, illicit dealers, or off the street.” And while there was no brand linked to all the cases, 66 percent of patients reported use of products under the brand name Dank Vapes.

“Dank Vapes appears to be the most prominent in a class of largely counterfeit brands, with common packaging that is easily available online and that is used by distributors to market THC-containing cartridges with no obvious centralized production or distribution,” the report read. Other brands patients most commonly reported using included Moon Rocks, Off White and TKO.

One caveat: The CDC’s investigation is ongoing. It’s also possible that, in the coming weeks, the agency will uncover another chemical, product, or brand linked to the cases.

The studies also involved self-reported data, and it’s possible people don’t remember what they used or are reluctant to share the details of their vaping or THC habits.

The brand details came from just two states, and the picture may look different in other parts of the country.

But for now, “The outbreak is pointing to a greater concern around THC-containing products,” Schuchat warned. At this time, she added, officials still aren’t narrowing their investigation at all.

So the agency continues to advise everybody — except smokers who are vaping to quit combustible cigarettes — to avoid using e-cigarettes.

It’s also adding an extra caveat: Be especially wary of THC-containing e-cigarette products.

A new study found the lung damage in this outbreak resembles people exposed to chemical spills

As of October 1, health officials in 48 states and the US Virgin Islands reported 1,080 confirmed and probable lung injury cases associated with e-cigarette use. The 18 deaths, meanwhile, have been recorded in 15 states.

Patients who have come down with the mystery lung injury started to experience symptoms anywhere from a few days to several weeks after using e-cigarettes.

So far, the patients have a few things in common, according to the CDC. They suffered from respiratory symptoms, including coughing, shortness of breath, chest pain, and difficulty breathing.

Nausea, vomiting, diarrhea, fatigue, abdominal pain, fever, and weight loss were also common symptoms.

On X-rays, patients’ lungs appear to be inflamed, as if a pathogen infected them. A new report, published in the New England Journal of Medicine, looked at biopsies of lung tissues from the people affected by the vaping-related illness. They found damage that resembled exposure to inhaled toxic substances, such as during a chemical spill.

When doctors have tried to find a common bacterial or viral source of the disease, they’ve failed to turn anything up. Again, patients only have vaping in common, but no specific products or substances link all the cases together.

That’s why an investigation is still underway, and officials are urging doctors and the public to report cases.

People who are concerned they’ve been harmed by an e-cigarette product should also contact their health care provider or local poison control center at 1-800-222-1222.

The outbreak isn’t the first to raise questions about the safety of vaping. From nicotine-induced seizures to injuries from vaping explosions to stress on the lungs and cardiovascular system, doctors and health researchers have been calling attention to vaping’s harms. But it is the first time vaping has been linked directly to deaths.

Listen to Today, Explained

Vox’s Julia Belluz explains what’s going on with the outbreak of a mysterious vaping-related respiratory illness that’s sweeping across the US.

Looking for a quick way to keep up with the never-ending news cycle? Host Sean Rameswaram will guide you through the most important stories at the end of each day.

Subscribe on Apple Podcasts, Spotify, Overcast, or wherever you listen to podcasts.

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His family thought vaping was safe, then he stopped breathing: What parents need to know

Getting to the bottom of the vaping mystery lung illness

Jake Wilson was relieved when his 25-year-old son Justin started vaping last year as a way to quit smoking.

“I thought it was a great idea. I was so happy that he wasn’t smoking anymore. Now, there was this healthier vaping,” Wilson, who lives in Portland, Oregon, told TODAY.

That all changed on Sept. 1 when Justin suddenly collapsed while eating dinner with friends, unable to breathe. It was the start of a frightening ordeal that left him unconscious for days and had doctors puzzled until they arrived at the official diagnosis: vaping toxicity.

Justin’s case is part of a vaping crisis that now includes hundreds of incidents of vaping-related illnesses across the country, according to the Centers for Disease Control and Prevention. At least six deaths have been reported.

After Justin’s nightmare, the father and son just want others to be careful about vaping.

“The experience was just insanity for me,” Justin Wilson, also of Portland, Oregon, told TODAY. “It’s all so new that nobody really knows long-term effects on it.”

“I would strongly urge anyone to stop [vaping]. Until the medical world can figure out what causing this, to just stop,” his father added. “We thought this was a safer alternative, but I don’t think it is anymore.”

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Justin had been using a Juul device and mint-flavored nicotine pods, his favorite. He bought mostly Juul products, plus the occasional off-brands available at stores. He would puff on the mint vapes constantly, draining about two pods a day.

They found e-juice in my lungs. It was starting to fill my lungs with liquid, pneumonia.

“I d the flavor. I d the product in itself,” Justin said. “I really enjoyed the act of smoking.”

Recreational marijuana is legal in Oregon, so he would also buy THC cartridges from dispensaries and go through them at a much slower pace — about once a month, he estimated. He bought nothing off the street, he said.

There were some concerns along the way: Justin had been diagnosed with asthma when he was 5, but he’d never had an asthma attack or needed an inhaler until after he started vaping, his father said.

Justin Wilson was unable to breathe on his own for days and even the regular ventilator wasn't enough to keep him alive, his family said. He finally recovered with the help of a special ventilator that delivered quick bursts of air and helped clear out his lungs.Courtesy Jake Wilson

Just before he suddenly collapsed this month, Justin felt a pressure on his chest that left him unable to breathe. His friends told him his face had turned purple, his lips were blue and he passed out.

Doctors thought it was an asthma attack, but Justin didn't respond to any asthma medication. At one point, his family was told Justin would die if he didn't improve quickly. Doctors discovered his lungs were coated with oil, leading to the diagnosis of vaping toxicity.

We apologize, this video has expired.

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Vitamin E oil found in some products has been part of the vaping-related illnesses investigation.

“They found e-juice in my lungs,” Justin said. “It was starting to fill my lungs with liquid, pneumonia.”

He finally got better with the help of a special ventilator and regained consciousness about five days later.

Justin believes the coils in his vaping device weren’t as hot as they should have been to fully vaporize the e-liquid, so he was breathing in small fragments of it into his lungs.

Another theory is that the heated vapor returned to oil form inside the cooler human body, his father said.

“There’s no way” Justin will go back to vaping, he said. Family friends are now throwing away their vape pens after learning about the ordeal, Jake Wilson added.

Vaping is not as safe as people thought it was, said Dr. Humberto Choi, a pulmonologist and critical care specialist at the Cleveland Clinic. Choi has treated several of the vaping-related illnesses and has recently been inundated by calls from parents worried their children are exhibiting worrisome symptoms.

“The best advice I could give to anyone is to stop vaping all together,” Choi said.

“We’re seeing young people with no other medical problems who come with coughing and shortness of breath, and when we do an X-ray and CT scan, we see signs of inflammation in both lungs.”

Some have been sick enough to be put on oxygen. Some require a ventilator.

We apologize, this video has expired.

CDC says stop vaping as mystery lung illnesses rise

Sept. 9, 201902:04

In the past, such cases would have been diagnosed as possible bronchitis or pneumonia, but they’re now being evaluated for suspected vaping-related lung disease. The illness is challenging to diagnose so doctors basically have to exclude other causes infection, Choi said.

Part of the spike in possible cases is heightened awareness, and part of it is that more people are vaping, he added.

Because the e-liquids can contain oils, there’s concern about the potential for lipoid pneumonia — an inflammation of the lungs caused by oils — but that’s not the pattern Choi has seen at the Cleveland Clinic. Nor are black-market products necessarily to blame: Some of Choi's patients have only used a regular branded vaping device, not something tainted or bought on the street.

The CDC is still looking for a common pattern or substance that could explain the crisis, but for now, the only common pattern is the act of vaping, Choi noted.

Any new respiratory symptom should be reason for concern, including:

  • coughing
  • shortness of breath
  • chest tightness
  • wheezing
  • general symptoms extreme fatigue or fever are also warning signs.

“If someone is vaping and has these symptoms, they should probably be seen,” Choi said.

“Most of the symptoms, when they’re mild, probably can be seen in the office. When they’re severe or showing up very fast, they should be seen in the ER, especially shortness of breath and chest tightness.”

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