Los Angeles Times - 26.08.2019

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Dr. John E. Parker was

working at a West Virginia

hospital in 2015 when a 31-

year-old woman was admit-

ted with acute respiratory

problems. A team of doctors

ultimately suspected that

her mysterious case of lipoid

pneumonia might be related

to vaping and weren’t sure

they had seen anything like

it before.

The doctors were in-

trigued enough to publish a

case report — a type of study

on unusual or provocative

patient findings — in the

medical journal Chest. Case

reports can serve as a call to

the medical community to

be on the lookout, though

they sometimes raise more

questions than they provide

answers.

This summer, almost

four years later, federal offi-

cials began investigating a

national outbreak of severe

lung illnesses linked to

vaping that has struck more

than 150 patients in 16 states.

Parker, a professor of pulmo-

nary critical care and sleep

medicine at West Virginia

University, described what

happened.

What were the patient’s

symptoms when she

arrived?

We would view them as

classic for what is getting to

be called vaping-associated

lung disease. She was very,

very short of breath and had

a cough, and we were, of

course, very worried that

she might have pneumonia

or some other acute respira-

tory illness. And then she

was so sick she needed to be

intubated.

What happens next in cases

like these?

We look for things like a

[hemorrhage] or an active

infection. And then for

lipid-containing macro-

phages. And then we usually

start some antibiotics [and

a] low-dose steroid and then

support the patient with a

ventilator and oxygen and

nutrition. And then just

kind of wait and see if any

other cultures come back to

prove anything different

than what you might be

thinking.

Early on, we just felt like

it was an unusual case and

may not be a common viral

or bacterial infection.

How did you figure out the

cause of her lipoid pneumo-

nia was e-cigarettes?

It’s a diagnosis of exclu-

sion. We excluded other

[options], and it became the

most likely cause.

We were convinced

enough that the case was

submitted for publication

and was accepted.

Once you realized vaping

could be to blame, did you

contact the Centers for

Disease Control and Pre-

vention or the Food and

Drug Administration or

any other regulatory

agency to tell them about

this?

We did not.

We felt at the time that

putting it in the medical

literature was appropriate.

And if other case reports

from other parts of the

country came forward, then

we’d have more of a cluster-

ing of findings that might

then warrant research

agencies [getting a] better

understanding [about] the

cause of the disease.

Which federal agency

would you report it to, if

you did?

In 2015, the FDA, of

course, was still regulating

cigarettes, but I don’t think

the government had yet

decided who would regulate

vaping products. So I’m

sure it was unclear who we

should call.

Did you or your team think

this was a one-off event

when you witnessed it?

We really felt that it

wasn’t going to be a one-off

event and that it was what

we usually called in public

health a “sentinel” health

event ... that it was an exam-

ple of a respiratory illness

that can be caused by this

exposure and that it prob-

ably wasn’t the first case

ever seen, nor would it be

the last.

Was it the first case that

you had seen at your insti-

tution?

To our knowledge it was

our first case, but we are

humble enough clinicians to

realize we may have missed

some other cases that we

interpreted [as] viral pneu-

monia or bacterial pneumo-

nia.

Have you seen more cases

since then?

I know we’ve seen a case

[of alveolar hemorrhage

syndrome] that we pub-

lished, and in polling some

colleagues we think we’ve

probably also seen [cases

of] cryptogenic organizing

pneumonia as well as lipoid

pneumonia and acute

eosinophilic pneumonia.

Yeah, we’ve certainly

seen at least probably four

forms of lung disease from

vaping.

If your team was seeing this

in 2015, is it possible that

it’s been happening in the

four years since then and

people just aren’t aware?

I really have every reason

to think we were not the first

ones to see it, by any means.

And I don’t think we

were even the first ones to

report it. I think that there

were some clusters in Wis-

consin and some other

places in the U.S. I also

know that the Japanese

have been very interested.

They’ve probably got four or

five papers at least in the

medical literature about

vaping-related lung injury.

Do you have a theory of

what might be causing the

lipoid pneumonia cases?

We need a strong multi-

disciplinary team to under-

stand the real etiology and

cause of lung injury from

inhalation.

I think it could be any

number of components in

the mixtures. Lungs don’t

like oil in general, and prob-

ably the most specific agent

that’s been studied recently

is diacetyl, which was stud-

ied in popcorn-flavoring

lung disease.

Have these kinds of cases

changed the way you ap-

proach patients?

Yeah, we search very

carefully for a history of

vaping.... I think it’s quite

important to understand if

they might be using inhaled

agents or vaping that might

present new toxicities to the

lung.

Will these illnesses have

long-term health effects?

An inhalational injury

may cause an acute lung

injury that’s life-threatening

and that someone may

survive from and have no

long-term sequelae [health

consequences].

But there also is the

possibility that long-term

[e-cigarette] use may cause

more insidious or chronic

diseases from which there

may not be a full recovery.

Knight is a correspondent

for Kaiser Health News, an

editorially independent

publication of the Kaiser

Family Foundation.

BACK STORY

Years ago, a warning about

vaping-related lung disease

A mysterious 2015 case could help shed light on this year’s outbreak

By Victoria Knight

THIS SUMMER, federal health officials began investigating a rash of severe lung

illnesses linked to vaping that has struck more than 150 people in 16 states.

Frank Franklin IIAssociated Press

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