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Hosp Pract (1995). Author manuscript; available in PMC 2022 April 01.
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Published in final edited form as:

Hosp Pract (1995). 2021 April ; 49(2): 79–87. doi:10.1080/21548331.2020.1843282.

Electronic Cigarettes and Vaping-Associated Lung Injury

(EVALI): A Rural Appalachian Experience
Rahul Sangania, Edward Rojasa, Michael Fortea, Rafia Zulfikara, Nicole Princeb,c, Antonios
Tasogloud, Travis Goldsmithe, Gary Casucciod, Jonathan Boydc,e,f,g, I. Mark Olferte,g,h,
Melina Flanagani, Sunil Sharmaa
aSectionof Pulmonary, Critical Care and Sleep Medicine, West Virginia University School of
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Medicine, Morgantown, WV, USA;

bC. Eugene Bennett Department of Chemistry, West Virginia University, Morgantown, WV, USA;
cDepartment of Orthopedics, West Virginia University School of Medicine, Morgantown, WV, USA;
dRJ Lee Group, Inc., Monroeville, PA, USA;
eDepartment of Physiology and Pharmacology, West Virginia University School of Medicine,
Morgantown, WV, USA;
fOccupational
and Environmental Health, West Virginia University School of Public Health,
Morgantown, WV, USA;
gCenter of Inhalation Toxicology (Itox, WVU Robert C. Byrd Health Science Center, Morgantown,
USA;
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hDivision of Exercise Physiology, West Virginia University School of Medicine, Morgantown, USA;
iDepartment of Pathology, Anatomy, and Laboratory Medicine, School of Medicine, West Virginia
University, Morgantown, WV, USA

Abstract
Background: Electronic cigarette use has increased dramatically since their introduction in
2007. Respiratory complications, particularly lipoid pneumonia, have been reported as early as
2012. An outbreak of pulmonary injury in 2019 has been reported in patients using vaping
products.

Research Question: To describe a rural Appalachian tertiary center’s experience of EVALI and
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to identify novel mechanisms of pulmonary injury patterns.

CONTACT Sunil Sharma ✉ sunil.sharma@hsc.wvu.edu Section of Pulmonary, Critical Care & Sleep Medicine, Director of MICU &
Pulmonary and Sleep Medicine Program Development, Department of Medicine, PO Box 9166, Health Science Center North, Room
4075A, Morgantown, WV 26506.
Declaration of financial/other relationships
The contents of the paper and the opinions expressed within are those of the authors, and the authors decided to submit the manuscript
for publication.
Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.
Declaration of interest
No, potential conflict of interest was reported by the authors.
 Sangani et al. Page 2

Study Design and Methods: We present a consecutive case series of 17 patients admitted
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to our rural, academic, tertiary care institution with EVALI from August 2019 to March 2020.
Demographics, baseline characteristics, co-morbidities, vaping behavior, and hospital course were
recorded. Broncho-alveolar lavage specimens were assessed for lipid-laden macrophages and
hemosiderin-laden macrophages with stains for Oil-Red-O (n = 15) and Prussian Blue (n = 14)
respectively.

The patient volunteered e-liquid materials (n = 6), and vapors were analyzed using a proton
transfer reaction time-of-flight mass spectrometer (PTR-TOF-MS) to describe the chemical
profile. Post-discharge interviews were conducted.

Results: The most common CT finding was bilateral ground-glass opacities with a predilection
for lower lung zones. The most frequent pulmonary injury pattern was lipoid pneumonia. The
majority of EVALI patients were critically ill requiring ventilation or ECMO. The most severely
ill patients were noted to be positive for iron stains in macrophages and showed higher volatile
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organic compound (VOC) levels in chemical analysis.

Interpretation: Based on our experience, EVALI in rural Appalachia presented with relatively
severe respiratory failure. Worse outcomes appear to be correlated to high levels of VOCs, iron
deposition in lungs, and concomitant infection.

Keywords
Electronic Cigarettes and Vaping-Associated Lung Injury (EVALI); rural Appalachian region;
lipoid pneumonia; iron; volatile organic compounds

Introduction
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Recent case clusters of severe pulmonary injury associated with the use of electronic
cigarettes have been reported since July 2019 [1–3]. Considering this outbreak, the Centers
for Disease Control and Prevention (CDC) developed surveillance case definitions for
confirmed and probable cases of Electronic Cigarettes and Vaping-Associated Lung Injury
(EVALI) [1,4]. As of 18 February 2020, a total of 2,807 hospitalized EVALI cases have
been reported by the CDC, spanning across all states of the United States, and 68 deaths
have been confirmed in 29 states. With ongoing investigations and national interest sparked
in the current outbreak of EVALI, we report the first case series of EVALI from the rural
Appalachian population of West Virginia [5].

Electronic cigarettes (E-cigarettes) entered the marketplace in 2007, and since 2014, have
rapidly become the most commonly used tobacco products among youth in the USA [6].
The prevalence of nicotine vaping has steadily increased since 2017, with approximately
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21% of the high school adolescents endorsing the current use of e-cigarettes [7]. Rural
populations, such as States in the Mid–West and Appalachia Region (e.g. West Virginia)
of the US are of particular concern since adult and youth tobacco use remains among the
highest in the USA [8], and there is evidence that West Virginia youth vaping rates are
rising faster compared to any other states in the US [9]. Despite such concerns, the reported
prevalence of hospitalized EVALI cases or death in Appalachian region remains low [5,10].

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E-cigarettes, also known as Electronic Nicotine Delivery Systems (ENDS), include a

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diverse group of battery-powered devices that produce an aerosol by heating liquid which
typically contains a solvent (vegetable glycerin-VG, propylene glycol-PG, or a mixture),
flavoring agents (e.g. diacetyl and 2,3-pentanedione), and nicotine[11]. The evaporation
of the liquid on the heating element is followed by rapid cooling to generate an aerosol
that is directly inhaled or ‘vaped’ by the user through a mouthpiece. Vaping of propylene
glycol and glycerol aerosols at high wattage and in large amounts was shown to induce a
sustained gas-exchange disturbance and lower respiratory tract epithelial injury in young
healthy tobacco smokers. [12] In addition to the expected chemical components, identified
contaminants include polycyclic aromatic hydrocarbons, nitrosamines, volatile organic
compounds (VOCs), toxic metals, and endotoxins [13]. The recent outbreak of EVALI
cases has also demonstrated the popular use of tetrahydrocannabinol (THC)- or cannabinoid
oil (CBD)-containing products in addition to nicotine only products; however, the specific
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chemical exposure(s) leading to lung injuries remains unknown at this time [1,3]. Moreover,
previous investigations have shown persistence of residual symptoms and abnormalities in
radiographic imaging and pulmonary function tests at follow up [14].

Our center was one of the first to report a case of severe lipoid pneumonia leading to
mechanical ventilation in 2015 [15]. This current series attempts to define the clinical
presentation, cytopathological features, chemical analysis of vaping material and post­
discharge follow-up in patients admitted for EVALI in the Appalachian region.

Methods
The study protocol was reviewed and approved by our institutional review board at West
Virginia University (IRB protocol ID# 1910758351, approval date 10/28/2019). Informed
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consent was obtained from patients prior to each indicated procedure (e.g. bronchoscopy)
as a part of their clinical care during the hospital stay. We collected consecutive EVALI
cases admitted to a rural, academic, tertiary care institution from August of 2019 till March
of 2020 as a part of a local institutional Vaping Action Task Force. A similar system-wide
approach of standardization for effective management and reporting of EVALI cases has
been previously recognized[14]. Detailed clinical characteristics were obtained including
vaping behavior and post-discharge follow-up. We also included our first case of EVALI that
was previously reported in 2015 [15].

We collected volunteered e-liquid material (n = 6) from these patients and performed

detailed chemical analysis (n = 3). RJ Lee Group (Monroeville, PA) provided the
instrumentation and analysis of vapors. The E-cigarette vapors were characterized using
a proton transfer reaction time-of-flight mass spectrometer (PTR-TOF-MS). Common
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substances between devices were identified, and the measured exposure profiles were
compared to a Juul device on the same instrument to identify the unique chemical signature.

As a part of standard clinical practice, most hospitalized patients underwent fiberoptic

bronchoscopy (n = 15). Bronchoalveolar lavage (BAL) specimens were obtained and
assessed for lipid-laden macrophages with Oil-Red-O stain (n = 15) and for hemosiderin­
laden macrophages Prussian Blue stains (n = 14). The BAL specimens were processed

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 Sangani et al. Page 4

as Thin Prep monolayer preparations, per our standard laboratory protocols. Oil-Red-O
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stains were performed on Thin Prep slides as part of the clinical cases. Cell blocks were
prepared from BAL specimens using the plasma-thrombin method, and Prussian Blue stain
was performed on cell blocks unless Prussian Blue stain had been previously part of the
clinical case (n = 3). The percentage of macrophages with Prussian blue staining (indicative
of hemosiderin) was quantified.

Results
Clinical characteristics
As part of a hospital vaping task force, we evaluated 17 consecutive patients admitted to the
West Virginia University Hospital from August 2019 to March 2020. Based on the definition
provided by the CDC, 14 were confirmed EVALI, and 3 were probable EVALI [1,4]. All
patients were seen by the pulmonary consultant (n = 17) or admitted to the Intensive care
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unit (n = 10). Table 1 summarizes the baseline characteristic of our cases (n = 17) and
Table 2 describes detailed vaping behavior. All patients, except two, underwent fiberoptic
bronchoscopy to evaluate for infection.

The mean age in our cohort was 37 years (±15 SD, range 18–73 years). The number of
patients who underwent urine drug screening (UDS) was 13/17 (76%). The median stay of
hospitalization was 8.5 days (±7.5 SD, range 3–33 days); all presented with dyspnea (100%)
and 12 (71%) had cough and fever. Of the 17 patients, 14 (82%) had leukocytosis. Thirteen
patients had a history of cigarette smoking, and four were never smokers. All patients
underwent a CT scan of the chest. Of the 17 patients, 14 (82%) had findings of ground
glass opacification (GGO) on CT scan with the majority having basilar predominance and
subpleural sparing. Of the 15 patients who underwent BAL, 13 (87%) were Oil-Red-O stain
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positive (rare staining to a maximum of 80%) and 4 (27%) were positive for Prussian blue
stain. Of the 13 patients tested, 9 were also consuming THC (9/13 positive UDS). Of the
nine patients exposed to both vaping and THC, 7 (78%) required critical care. Of the 17
patients, 4 (24%) had a concomitant infection. The results of the BAL/nasal swab samples
showed the presence of the virus in two patients (Rhinovirus/Enterovirus and Influenza A),
presence of bacteria in one patient (Streptococcus pneumoniae and Klebsiella pneumoniae),
and presence of both bacteria and virus in one patient (Enterovirus and Streptococcus
pneumoniae). These were included as probable EVALI patients based on CDC guidelines of
vaping exposure within the last 90 days and clinical suspicion of the team that the infection
was not the sole cause of patients’ respiratory failure [4].

Ten patients required mechanical or noninvasive ventilation, and two patients underwent
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veno-venous ECMO therapy. Of the 17 patients, all patients survived to hospital discharge.
However, one patient sustained out-of-hospital cardiac arrest 3 weeks post-discharge, of
unclear etiology, resulting in death.

Bronchoalveolar lavage (BAL) cytopathology analysis

Thirteen were positive for lipid-laden macrophages (Figure 1) by Oil-Red-O stain (rare
staining to a maximum of 80%). Excluding the rare staining and considering microbiology

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 Sangani et al. Page 5

and overall clinical profile, nine patients were diagnosed with lipoid pneumonia (Oil-Red-O
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ranging from 25% to 80%).

Four specimens were strongly positive for hemosiderin-laden macrophages by Prussian blue
stain, ranging from 60% to 90% (Figure 1). Most BAL samples (75%) had neutrophils
predominant cellularity (55%–80%), negative microbiology, and markedly lipid-laden
macrophages on Oil-Red-O stain (40%–75%). All were hypoxic on presentation, while
two patients required MICU admission for high-grade hypoxemia (one requiring HFNC and
other mechanical ventilation). All had clinical syndrome consistent with lipoid pneumonia
and confirmed EVALI as per CDC definition, requiring supportive treatment with empiric
antibiotics and a tapering dose of corticosteroids.

Chemical analysis of vape aerosol

Six of the 17 patients voluntarily provided samples of the vaping devices. The E-cigarette
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vapors were characterized using a proton transfer reaction time-of-flight mass spectrometer
(PTR-TOF-MS). Common substances between devices identified were formaldehyde (m/z
31), acetaldehyde (m/z 45), acetone (m/z 59), propylene glycol (m/z 77), cyclohexane (m/z
83), and nicotine (m/z 163), as shown in Figure 2. Samples from patients testing positive for
THC showed the presence of monoterpenes in aerosol chemical profiles, with one patient
(case 7) showing the presence of Linalool.

In one sample, evidence of monoterpenes was present at m/z 81 and m/z 137, and linalool at
m/z 157. The exposure profile from this sample was compared to a Juul device on the same
instrument, using methods by Wan, et al. [16] This method allows the direct comparison
of total mass spectral profiles and is used to estimate the similarity between all chemical
compounds detected. Generally, similarity scores above 20 suggest unique chemical profiles
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between the two spectra being compared. This sample produced an exposure similarity
score of 30, indicating the exposure had a unique aerosol profile compared to a Juul
device. In other words, this patient used a vaping device that produced significantly different
compounds than a Juul. These differences may be correlated to the severity of symptoms
observed. The three most severe cases (two requiring ECMO and other prolonged intubation
and mechanical ventilation [cases 4, 7, and 15]) were found to have high levels of total
VOCs (Figure 3).

Post-discharge follow up
A follow-up of these patients in 6–12 weeks was conducted on all patients. (Table 2) Out
of the 17 patients, 12 reported complete cessation of vaping or smoking post-discharge
and resolution of respiratory symptoms. Of these 12 patients, 4 who stopped vaping,
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continued to have residual symptoms, including a persistent cough, dyspnea, and wheezing.
Two of these were on home oxygen. These patients had a history of heavy vaping
or performed Valsalva with vaping. Three patients continued to vape and also reported
persistent symptoms of cough and dyspnea. One of them, as previously noted, suffered
cardiac arrest and died approximately 3 weeks post-discharge.

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Discussion
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We report the first large case series of EVALI from an academic center in the rural
Appalachian region. To our knowledge, this is the first comprehensive series with one)
BAL analysis via Oil-Red-O and quantitative Prussian blue stains, 2) chemical analysis of
vaping liquid, and 3) post-discharge interview.

Our series of consecutive patients hospitalized with a diagnosis of EVALI shows a

significantly higher proportion of critically ill patients compared to other series [17], with
10/17 (59%) requiring ICU care and 7/17 (41%) requiring invasive mechanical ventilation
or ECMO. Of the 17 patients, 9 had a history of using THC or were positive for THC on
UDS. Additionally, nine patients also had UDS positive for opiates (5), benzodiazepines
(3), cocaine (1), and amphetamines (1). The presence of drugs and additives in the vaping
compounds may also have played a role in the severity of EVALI in our series.
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Lipoid pneumonia has been reported as the predominant injury pattern with vaping-related
injuries [2,4]. In our series of 17 total patients, 9 (53%) were diagnosed with lipoid
pneumonia based on lipid-laden macrophages detected in BAL. Interestingly, only 4/9
patients with lipoid pneumonia had a history of THC use or a positive UDS. This differs
from recent findings by Blount et al., who reported vitamin E associated lung injury, 94%
of whom had detectable THC in BAL samples [18]. We believe the addition of flavoring
compounds or other additives in vaping products may be responsible for the ‘chemical
injury’ of the lung and disruption of surfactants [19,20]. Interestingly, this may redefine the
injury pattern as ‘endogenous’ lipoid pneumonia rather than previously reported exogenous
lipoid pneumonia [15,21].

Numerous acute and chronic respiratory diseases are associated with disrupted iron
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homeostasis in the lungs [22]. We identified four patients with lipoid pneumonia clinical
presentation with high BAL macrophage iron content. All these patients developed
leukocytosis and were hypoxic on presentation, requiring varying degrees of oxygen
support, ICU care, and mechanical ventilation. We hypothesize that high BAL macrophage
iron load may reflect the severity of underlying lung inflammation induced by e-cigarette
use and believe that this may be an important analysis in BAL for prognostication triaging of
EVALI patients admitted with respiratory distress.

Chemical evaluation, although limited to six patients, provided important insight. Propylene
glycol (a common base for liquid vaping solutions) and nicotine were detected in all
samples, as expected. Monoterpenes are related to plant products and essential oils and
suggest the presence of flavoring compounds of THC [23]. Monoterpenes were present in
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aerosol samples for all patients who tested positive for THC. One unique finding was the
presence of linalool, an anti-inflammatory substance with properties similar to vitamin E
acetate. Although linalool has shown some therapeutic potential [24,25], it can dysregulate
normal inflammatory pathways [26], which could potentially disrupt subsequent response to
pathogens and insults. The similarity in activity to vitamin E acetate may be coincidental,
but it may also offer a glimpse into potential mechanisms of toxicity associated with EVALI,
and E-cigarette additives with anti-inflammatory activity should be investigated further.

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Total VOCs (TVOCs) were elevated in the three most critical patients (Figure 3), requiring
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ECMO or prolonged intubation. An increase in VOCs may correlate to the severity of

respiratory failure noted in these patients. VOCs represent a complex mixture of hundreds
of low-level compounds, and high TVOC levels are associated with poor air quality. In
e-cigarettes, common VOCs detected are ethanol, acetonitrile, isopropyl alcohol, benzene,
and toluene, and exposure to these compounds is associated with irritation in the respiratory
tracts [27]. These additives may explain the lung injury in the absence of THC related
compounds.

Concomitant infection is not uncommon in EVALI, with isolation of microbes in 4/17

(24%) patients. This is supported by recent studies showing that vaping may lead to
compromised immunity and increased susceptibility to infection [20,28]. In addition, the
fact that the majority of patients presented with symptoms and findings indistinguishable
from pneumonia suggested that many patients may be under-diagnosed and under-reported if
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the careful and detailed history of vaping is not obtained.

In the context of a rural population, our experience confirms that EVALI is not just an urban
health-care problem. As opposed to prior reports, in which most of the cases were attributed
to lipoid pneumonia, our series suggested more diverse presentations and injury patterns.
Compared to other cohorts, our patients were older [17], had a higher proportion of illicit
drug use, and much sicker, with 12 (70%) requiring mechanical ventilation, noninvasive
ventilation, or ECMO. This could suggest regional differences to the access of vaping
products. Further, this (sicker) cohort had a median age of 33 years, as opposed to 23 in a
large national series [29].

Additionally, all cases reported so far have parenchymal and/or alveolar injury. Airway
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injury manifesting as trachea-bronchomalacia has been recently reported [30] and suggests
other mechanisms of injury or long-term consequences (this patient had been vaping for over
7 years).

Lastly, EVALI incidence has declined steadily since February 2020; however, there is
the emergence of the SARSCoV-2 global pandemic. Concerns were raised about the
convergence of these two respiratory illnesses given overlapping clinical and radiographic
findings [31]. A recent population-based study of young adults reported a five to seven-fold
increased risk of COVID-19 diagnosis among the e-cigarette or dual users of e-cigarette
and traditional cigarettes, respectively [32]. Moreover, preliminary evidence has also
suggested that nicotine (either via smoking or vaping) might upregulate the ACE2 receptor,
the portal of entry for SARS-CoV-2, and a crucial factor in its pathogenesis [33,34].
Considering the lack of long-term safety of e-cigarette devices, there is a need for ongoing
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research to determine its interaction with SARS-CoV-2 transmission and progression. This
understanding can potentially impact public health policies and may also identify novel
therapeutic approaches.

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Conclusion
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Compared to other case series around the country, our patients from Appalachia with
EVALI were older and had more severe respiratory failure. The presence of VOCs (possibly
secondary to impurities/additives), concomitant infection, and high iron content in BAL
appear to be highly correlated to severe respiratory failure and poor outcomes with EVALI
in this cohort (Figure 4). These additives most likely vary on a regional basis, especially
considering the wide range of vaping products available, some of which may be products
of ‘garage labs’. Furthermore, concomitant use of THC, opiates, smoking, and poor access
to medical care may be playing a role. Post-discharge significant proportion of patients
continues to have respiratory issues. As per the recent CDC guidelines [35], the increased
risk of readmission and death, patients with EVALI should be followed within 48 h and
strongly counseled on vaping cessation. Given the recent data showing that youth using
e-cigarettes are at increased risk for COVID-19, it is imperative that to improve public
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awareness and education on the risks of vaping.

Transparency
Declaration of funding
No, funding was received for the preparation of the manuscript.

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34. Sharma P, Zeki AA. Does vaping increase susceptibility to COVID-19?Am J Respir Crit Care Med.
2020101;202(7):1055–1056. [PubMed: 32749868]
35. Evans ME, Twentyman E, Click ES, et al.Update: interim guidance for health care professionals
evaluating and caring for patients with suspected E-cigarette, or vaping, product use-associated
lung injury and for reducing the risk for rehospitalization and death following hospital discharge
- United States, December 2019. MMWR Morb Mortal Wkly Rep. 2020;68(5152):1189–1194.
[PubMed: 31895915]
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Figure 1.
Photomicrographs of Broncho-Alveolar Lavage (BAL) Cytopathology Analysis showing
lipid-laden macrophages (Oil-Red-O stain, 200x; black arrow) and hemosiderin-laden
macrophages (Prussian Blue stain, 40x; red arrow), respectively.
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Figure 2.
Identification of chemical compounds in e-cig devices. The following chemical
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compounds were identified by proton transfer mass spectrometer (PTR-MS): formaldehyde

formaldehyde (m/z 31), acetaldehyde (m/z 45), acetone (m/z 59), propylene glycol (m/z 77),
cyclohexane (m/z 83), and nicotine (m/z 163), monoterpenes (m/z 81 and m/z 137), linalool
(m/z 157).
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Figure 3.
Concentration of TVOC’s in parts per million (ppm) for the samples tested.
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Figure 4.
Risk factors for severe respiratory failure. THC, tetrahydrocannabinol; TVOC, total volatile
organic compounds; *Hemosiderin laden macrophages (Prussian blue stain).
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Table 1.

Baseline characteristics, imaging, and laboratory findings of patients admitted with EVALI (N = 17).
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Baseline characteristics N (%) or mean or median

Males 10 (59%)
Age (18–73 years) 37/33
18–24 4 (24%)
25–35 6 (35%)
36 and older 7 (41%)
BMI (range: 20.3–39.5 kg/m2) 29.95
Symptoms/signs:
Respiratory:
1. Dyspnea 17 (100%)
2. Cough 12 (71%)
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3. Pleuritic chest pain 6 (35%)

GI: nausea/vomiting/diarrhea 9 (53%)
Fevers 12 (71%)
Constitutional symptoms (fatigue, myalgia, malaise etc. …) 12 (71%)
Hypoxemia
Past medical history 11 (65%)
1. Asthma/emphysema 5 (29%)
2. Mood disorders (anxiety, depression) 5 (29%)
Smoking: 13 (76%)
Pack years (range: 1–20) 11.3 pack years
Vaping behavior (see Table 2 for more details):
1. Nicotine only 9 (53%)
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2. Both Nicotine/THC 7 (41%)

3. Flavored 8 (47%)
4. Sharing the device 6 (35%)

5. Dabbing* 3 (18%)

6. Did Valsalva with vaping 5 (29%)

Labs:
1. Leukocytosis 14 (82%)
2. UDS checked (n = 13, 76%) and THC + 9 (53%)
Chest CT findings:
1. GGO 14 (82%)
2. Crazy paving pattern 5 (29%)
3. Consolidations 7 (41%)
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4. Nodules (predominant pattern) 2 (12%)

Bronchoscopy performed (n = 15/17, 88%)
1. Cellular pattern: 11 (65%)
a. Neutrophilic (54–97%) 4 (24%)
b. Macrophage (33–70%) 1 (6%)

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Baseline characteristics N (%) or mean or median

2. Microbiology 1 (6%)
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a. Viral (Rhino/Entero) 1 (6%)

b. Viral (Rhino) plus streptococcus pneumoniae 1 (6%)
c. Influenza A 1 (6%)
d. Bacterial streptococcus pneumoniae/klebsiella pneumonaie 1 (6%)
3. Positive Oil-Red-O Stain (25%−80%) 9 (53%)
4. Positive Prussian Blue stain (60–95%) 4 (24%)
EVALI:
1. Confirmed 14 (82%)
2. Probable 3 (18%)
ICU with ventilation (noninvasive or invasive) 10 (59%)
ICU with ECMO 2 (12%)
Outcomes:
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1. Alive at discharge 17 (100%)

2. Overall survival 16 (94%)

*
Dabbing is a term used in reference to vaping of THC extracts

Abbreviations: ARDS- Acute Respiratory Distress Syndrome, BMI- Body Mass Index, ECMO- Extracorporeal Membrane Oxygenation, EVALI-
Electronic Cigarettes and Vaping-Associated Lung Injury, GGO- Ground Glass Opacity, THC-Tetrahydrocannabinol, UDS-Urine Drug Screen.
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Table 2.

Post-discharge telephonic survey/clinic visit.

Reusing
Type of device Type of liquid Sharing Dabbing Vaping behavior Post discharge symptoms
pods
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Case 1 Second generation­ Nicotine, Maddcatt No No Using for 3 months No respiratory symptoms
VISION SPINNER Vapors (Hawaiian Denied further use of vaping
II blast flavor)
Case 2 NDA Nicotine NDA NDA NDA Using for 1.5 years No respiratory symptoms
Denied further use of vaping
Case 3 Juul Juul cartridges Yes No No Using for 5 months No respiratory symptoms
2–4 puffs/hour Denied further vaping or cigarette
All day long use smoking
No Valsalva
No stealth vaping
Unsure of cloud volume
Case 4 VUSE VIBE Vibe cartridges No No No Using for 6 months Intermittent dyspnea, using nebulized
2–3 puffs every 30 mins bronchodilators
20 times per day vape use Continues to vape
Did Valsalva with vaping
No stealth vaping
Unsure of cloud volume
Case 5 Juul Menthol, Nicotine No No No Using for 6 months Minimal residual cough
5% PODS Smoked pods, 20 puffs a day, lasting 2 days Denied further vaping or cigarette
No symptoms with vaping smoking
No Valsalva
No stealth vaping
Small cloud volume
Case 6 NDA Nicotine, Recently NDA NDA NDA Using for few years, THC for last 6 months NDA
with THC
Case 7 Local pod devices Nicotine, THC and Yes Yes Yes 3 hours per day No respiratory symptoms
Refillable cartridges food flavors 2–3 puffs each time Denied further vaping
(Sourin) No stealth vaping
Small cloud volume, used THC oil occasionally

Hosp Pract (1995). Author manuscript; available in PMC 2022 April 01.
Case 8 Juul THC Vape Juul cartridges No No Yes Using for 2 months No respiratory symptoms
TETRA by Nucleus (Virginia tobacco) 6–10 puffs/hour Denies further vaping
Used 12–14 hours/day
Did Valsalva
No stealth vaping
Medium cloud volume
Case 9 MOD-POD, THC Nicotine and No No No Using Nicotine for 5 years, THC for 2 months 3–8 puffs a Residual dyspnea and intermittent
brand-Dank recently THC day, cartridge lasted 2 days cough
Symptoms started only with THC Dank liquid use Continue using nicotine vaping but not
Used nicotine vaping × 5 years THC
Did Valsalva with vaping Worrying about smoking relapse
No stealth vaping
Small cloud volume
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Reusing
Type of device Type of liquid Sharing Dabbing Vaping behavior Post discharge symptoms
pods
Case 10 Unknown brand Nicotine only Yes No No Using for 5 months but recently cut down to once a week × Cardiac arrest at 3 weeks post discharge
2 months and death
Notes cough, shortness of breath with vaping use Had continued to vape post discharge
Case 11 Juul Type, Nicotine and THC Yes Yes for No 1–2 puffs, once or twice a day No respiratory symptoms
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smoknovo-refill nicotine Cloud volume small with Juul Denies further vaping
yourself pods No for Using Juul × 2 years, last use one week ago, occasionally
THC smokes marijuana
Case 12 NJOY/Juul Nicotine and THC, Yes No Yes Using one pod a day, small cloud volume, did Valsalva No respiratory symptoms
mint flavor Denied further use of vaping including
THC
Case 13 E-cig × 5 yrs Mistic Nicotine only No Yes Vape No Vaped all day Severe trachea-bronchomalacia still
vape (online) Menthol flavored came with 50–60 puffs in span of 2hrs shortness of breath, coughing, brown
refill Vaping for last 7 years phlegm, noisy breathing, snoozing
noise on breathing heavy
Stopped vaping
Case 14 Sigelei Sobra 198 W Nicotine, Royal No No No Vaping daily for last few months NDA
Blood flavor
Case 15 Pod device, would Flavored nicotine No Yes No Using it for 6–8 hrs continuously Clinically on oxygen, still short of
refill oil (undefined) 2–3 puffs each time breath
Medium cloud size No ER visits.
No stealth vaping Denies further vaping
Case 16 Vape Pen THC CBD oil No No No 1–2 times a day initially On oxygen as needed
Then 5 times a day 4–5 puffs each time No symptoms with regular activity, heat
Smoke cloud small-medium and exertion maker her short of breath.
No stealth vaping Occasional cough mostly morning
Did valsalva Denies further vaping
Case 17 Juul (rarely) Rig Nicotine Yes Yes No Vaping for 6 years No respiratory symptoms
(mostly) bigger Lonlonmilk (6% Continuous whole day every few mins Denies further vaping
pods. Box shaped nicotine) 2–3 puffs each time
with a tank. Refilled Medium cloud size
it mostly Stealth vaping occasionally.
No Valsalva

Hosp Pract (1995). Author manuscript; available in PMC 2022 April 01.
NDA: no data available

THC: Tetrahydrocannabinol

CBD: Cannabidiol
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