Deadly combination of Vaping-lnduced lung injury and Influenza: case report

Abstract

Background: E-cigarette and vaping use-associated acute lung injury (EVALI) has been recently recognized as a complication in individuals who use vaping devices. Another consideration is that EVALI may have an adverse influence on the outcome of intercurrent respiratory infections. We document this deadly combination in the case of a young man who had EVALI and simultaneous Influenza-A infection leading to severe Acute Respiratory Distress Syndrome (ARDS). Case presentation: A 27-year-old male with a history of tobacco and vaping use was admitted to hospital after two weeks of flu-like symptoms, diarrhea and vomiting. A chest x-ray was consistent with multifocal pneumonia, and microbiological tests were positive for Influenza-A and methicillin-sensitive Staphalacoccus aureus (MSSA). Bronchoscopy provided evidence of acute inhalational injury. After admission, he acutely decompensated with severe hypoxia and hypotension; he required intubation, sedation and vasopressors. He developed sepsis with acute kidney failure, liver failure, biventricular systolic dysfunction and severe rhabdomyolysis. He was placed on veno-venous (VV) extracorporeal membrane oxygenation (ECMO) initially and later changed to Veno-Arterial (VA) ECMO. Nevertheless, the patient continued to deteriorate, and he expired two weeks after admission. Conclusion: This case documents that EVALI can act as a major factor leading a respiratory infection to progress into severe ARDS with a fatal outcome.

Fundamentals of Vaping-Associated Pulmonary Injury Leading to Severe Respiratory Distress

“…While most vapers do not experience overt symptoms of VAPI, let alone exhibit pulmonary failure, a small subset of users succumb to this type of injury. (10)(11)(12)(13)(14)(15)(16)(17) Such severe VAPI cases arise in users of commercially available vaping products, unlike the EVALI epidemic in 2019 traced back to black market "Dank Vapes" associated with ill-conceived mixing of Vitamin E acetate and THC into vape juice. (48,49) EVALI syndrome often presented as ARDS with fulminant inflammation in the respiratory tract.…”

“…(4)(5)(6) In comparison, pathological processes culminating in severe VAPI are more obscure and slow to develop, in some cases occurring over months of frequent unrelenting vaping activity. (10)(11)(12)(13)(14)(15)(16)(17) Thus, rather than model lung injury using xenobiotic agents that induce rapid and overwhelming inflammatory activity within hours such as bleomycin or meconium, (77,78) the conceptual framework for this study was to use widely available retail vaping technology and product combined with an extended exposure protocol consistent with topography of a high intensity vaper likely to develop VAPI leading to hospitalization.…”

“…(7)(8)(9) However, Vaping-Associated Pulmonary Injury (VAPI) in a minority of users is a well documented and growing concern in the clinical setting with multiple independent reports of severe respiratory illness including Acute Respiratory Distress Syndrome (ARDS) including potential pulmonary circulation impairment. (10)(11)(12)(13)(14)(15)(16)(17) Life-threatening consequences of VAPI emphasized by high profile media coverage over the last couple of years have raised public awareness of danger linked to vaping (18)(19)(20)(21) with increased calls for regulatory oversight and expanded research. (22,23) Fundamental unresolved issues using commercial vaping products from reputable sources include 1) why do particular individuals develop VAPI; 2) what is the underlying pathogenesis of VAPI leading to respiratory distress; and 3) how does progression of VAPI precipitate pulmonary circuit failure?…”

E-cigarettes in the COVID-19 era

“…In addition, a recent report identified the risk for the development of severe lung injury due to e-cigarette smoking,[ 4 ] a syndrome described as vaping use-associated acute lung injury (EVALI). [ 5 ] EVALI contributes to the compromise of the lung capacity due to remodeling and inflammation, further increasing the risk for respiratory disorders and/or compromising established ones.…”

“…presented evidence that vaping can increase the airway inflammation and type-2 cytokines in the lungs of mice submitted to an allergic lung inflammation protocol. [ 1 ] Moreover, a recent report identified a lethal case of influenza in a patient with EVALI,[ 5 ] indicating a possible link between e-cigarettes and severe response to respiratory viral infections.…”