As reports accumulated of people stricken with lung disease after they used e-cigarettes, important clues emerged from a local emergency department.

By Sarah Ovaska-Few

A North Carolina hospital offered some of the first clues into what’s been an ongoing medical mystery, the vaping-related lung injuries that have killed 18 people in the country to date and sent more than a thousand to hospitals with serious injuries.

Officials with the Centers for Disease Control and Prevention announced the new death count Thursday afternoon and continued to strongly urge people to avoid using any vaping or e-cigarette devices given the current dangers and unknown nature of the current health crisis.

“I wish we had more answers,” said Anne Schuchat, CDC’s principal deputy director. “This is a critical issue.”

Doctors at the WakeMed Raleigh campus saw three relatively young adults come in within a week of each other this summer, all struggling to breathe and with no other obvious signs of what could be causing their distress, said Kevin Davidson, one of the critical care pulmonologists at WakeMed, in an interview with N.C. Health News.

All three patients told doctors they recently vaped some form of Tetrahydrocannabinol

(THC), the active compound in marijuana that leads to the characteristic high. Davidson and his colleagues quickly realized there may be a danger that stretched far beyond the treatment rooms of the Raleigh hospital.

“We immediately knew there was something wrong and we picked up the phone” to call state health officials and the CDC, Davidson said. He recalled relaying, “’I’ve never made a report like this, but I think there’s something wrong with these young vapers.’”

Davidson and his colleagues ended up authoring a brief case report about five vaping-related cases, which was published in mid-September in the CDC’s Morbidity and Mortality Weekly Report and mentioned the link to THC as well as diagnoses of lipoid pneumonia, a rare condition that occurs when fat particles enter the lungs. It was an early, but important, puzzle piece to help doctors around the country in their quest to figure out what exactly has been causing the lung injuries to e-cigarette users that are in the news.

Davidson’s scientifically deduced hunch about a link to THC products appears to have panned out. CDC experts last week issued particular caution against vaping THC-containing substances after the agency – building on reports from around the country – found that among 578 lung injury patients, about 78 percent reported vaping THC in the three months prior to presenting with the injuries, with 36 percent indicating they’d only vaped THC, and no nicotine.

Most of the people affected bought their THC vaping cartridges from the streets or from dealers, according to CDC officials. Cartridges of vaping substances are being tested by the FDA to pinpoint what precisely is harming people. The FDA is also looking at links between THC substances and the presence of vitamin E, according to FDA officials.

On Thursday, Schuchat also addressed discrepancies between the report by the WakeMed clinicians and a letter published this week in the New England Journal of Medicine by Mayo Clinic doctors that examined 17 different patients with vaping-related lung injuries and found no signs of lipoid pneumonia.

She emphasized that both hypotheses could end up being true, given that so much is unknown about what is in vaping and e-cigarette cartridges and what is behind the recent lung injuries.

“It’s early days in understanding the full clinical spectrum and the pathology of lung injuries following e-cigarette use or vaping,” Schuchat said. The September WakeMed report “came from a group of clinicians in North Carolina and I think it was very helpful in raising questions and alarms.

“There may be a lot of different nasty things in e-cigarettes or vaping products and they may cause different harms in the lungs,” she said.

Emerging research

Public health officials have been issuing warnings for years about the potential, though largely unknown, dangers of e-cigarettes and vaping. They’ve pointed, in particular, to the meteoric rise of JUUL use among teenagers and young adults during a time when cigarette and other tobacco use were at record lows. JUUL, the e-cigarette start-up company that captured a majority of the e-cigarette market, is facing tightening regulations under the FDA. Multiple lawsuits have also been filed by state attorneys general, including N.C. Attorney General Josh Stein, accusing the company of illegally targeting youth through marketing with the flavored nicotine products.

E-cigarettes have been seen by some as a way of delivering nicotine to those already addicted in a way that’s less harmful than traditional cigarettes, with their well-known links to cancer and declines in life expectancy.

But in a paper released this week in the BMJ (British Medical Journal), scientists, including one from Duke University and another from the University of North Carolina at Chapel Hill, found that the long-term effects of vaping nicotine salts and other substances found in various vaping liquids may not be fully understood yet but preliminary data is pointing to harmful effects. The authors determined that e-cigarette aerosols can harm lungs on the cellular level as well as how the organ functions in the overall immune system, and vaping “will likely prove to have at least some pulmonary toxicity with chronic and possibly even short term use.”

Another paper published last month by UNC researchers in the American Journal of Respiratory and Critical Care Medicine found the lungs of vapers had elevated levels of protease enzymes, which has led to emphysema in smokers.

“Our findings in this study indicate that vaping may not be safer than cigarette smoking,” said Robert Tarran, a professor of cell biology and physiology at the UNC School of Medicine, in a release about the study.

But the recent reports of lung injuries are not just about the unknown dangers of long-term use of inhaling nicotine through vaping devices or pushing a new generation toward nicotine addictions.

First noticed this summer, hospitals around the country have been treating people for severe lung injuries, conditions that have required ventilators and stays in intensive care units. This has left doctors to speculate a particular substance in vaping compounds is leading to the sudden onset of respiratory issues.

Eighteen have died, with the recent death of a Virginia resident at Greensboro’s Cone Health system included in that count. Schuchat said there are additional deaths being reviewed, and she expected the death toll to rise.

The CDC, state-level health officials and others around the country are scrambling to analyze commonalities among patients while urging people to stop vaping or using e-cigarettes until they can pinpoint an exact reason for the injuries.

“This is still very much something that is under investigation,” said Zack Moore, a pediatrician who serves as the state epidemiologist with the N.C. Department of Health and Human Services. “Avoid vaping and e-cigarettes while this investigation is still undergoing.”

NC doctors spotted early cases

Davidson, the WakeMed pulmonologist at the Raleigh hospital, said he and his colleagues were taken aback by the relatively young ages of the patients exhibiting what’s since been linked to vaping.

It was a perplexing combination – people in their 20s who are relativity healthy don’t often need a pulmonologist’s help. It’s a rare situation where Davidson is called to the bedside of a young person who has been in otherwise good health, he said.

The symptoms also initially seemed to resemble infection-related pneumonia, a serious respiratory condition that can be a killer for those with weakened immune systems.

But, again, “people in this age group don’t get pneumonia,” Davidson recalled thinking when presented with his first ailing patient.

Bronchoscopies – procedures where a thin tube is passed through the nose or mouth and led into the lungs for biopsies or ultrasounds – were performed and though there were clusters of white blood cells, typically a sign of an infection, ineffective rounds of antibiotics showed that a more typical infection wasn’t the culprit.

The patients were diagnosed with lipoid pneumonia, which is when fat enters the lungs and causes negative reactions.

CDC closely tracking reports

The CDC is getting closer to cracking the medical mystery, with data from hospitals around the country like WakeMed and the Children’s Hospital of Wisconsin, the first in the country to raise alarms about the mystery lung ailments.

North Carolina has seen 40 cases, ranging in ages from 16 to 72, with patients experiencing severe cough and shortness of breath in addition to fever, fatigue, chest pain, nausea, vomiting or diarrhea, according to ongoing updates provided by the N.C. Department of Health and Human Services.

The CDC’s Schuchat said in a call with reporters last week that the crisis related to the vaping shows no sign of slowing and health officials expect the death toll to continue to rise.

“Sadly, I do believe there will be additional ones,” said Schuchat, the principal deputy director of the CDC, said of deaths due to vaping. “[T]his is a very serious threat right now to young people across the country and we don’t want there to be more deaths.”

That’s why, Schuchat said, the agency wants people to avoid e-cigarettes and vaping products right now, especially those with THC, until there are more answers as to what is causing the lung injuries.

Update: This story originally spelled N.C. DHHS epidemiologist Zack Moore’s name as Zach Moore and has been corrected. A quote attributed to the CDC’s Anne Schuchat from a Thursday call with reporters was also expanded to offer more context.