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A 17-year-old boy with asthma, who had been vaping 50 to 100 puffs daily of unmodified mango and mint-flavored JUUL pods (JUUL Laboratories) for 3 years and prefilled counterfeit THC cartridges for 1 year, presented with pleuritic chest pain and progressive dyspnea. He was not smoking any other substances but had briefly tried combustible cigarettes 1 year prior. Examination revealed tachypnea, diminished aeration, and oxygen saturation as measured by pulse oximetry of 87% on room air. His initial chest radiograph was unremarkable. Urine toxicology screened positive for cannabinoids. He was admitted to the ICU for high-flow nasal cannula and underwent chest computed tomography with angiography (CTA) to screen for pulmonary embolism. CTA revealed no embolism, but significant lung parenchymal abnormalities were present (Figure 1). Empiric antibiotics were started. A transbronchial biopsy demonstrated acute fibrinous organizing pneumonia (AFOP) (Figure 2), so he was started on 1 mg/kg/d (80 mg) of intravenous methylprednisolone. He required bilevel positive airway pressure after biopsy but was weaned from all noninvasive ventilatory support after 3 days of treatment. Steroids were then tapered over 9 days with oral prednisone. He was asymptomatic 1 month later, after e-cigarette cessation.
Figure 1. Computed tomography with angiography of the chest with high-resolution cuts revealing basilar-predominant ground-glass opacities with septal thickening and pneumomediastinum. Subpleural lung is spared.
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Figure 2. Acute fibrinous and organizing pneumonia characterized by intraalveolar fibrin balls and neutrophils (black arrows). The image shows background fibromyxoid and histiocytic foci with intraalveolar fibroplasia (single arrowhead) and concomitant organizing diffuse alveolar damage (white arrows) with reactive type II pneumocyte hyperplasia (double arrowhead).
[More] [Minimize]AFOP presents with diffuse ground-glass infiltrates and intraalveolar fibrin balls (1). Subpleural sparing and pneumomediastinum, described elsewhere in vaping-associated lung injury, were also seen here (2, 3). This patient’s presentation fits with existing literature, but his young age, choice of e-cigarette, and lung pathology are unique (4). The images characterize AFOP, a newly evolving rare lung pathology within the field of pulmonology, which is associated with vaping. Clinicians should routinely screen their patients for use of e-cigarettes or vaping products and, in particular, inquire about the specific substances being inhaled.
| 1. | Zare Mehrjardi M, Kahkouee S, Pourabdollah M. Radio-pathological correlation of organizing pneumonia (OP): a pictorial review. Br J Radiol 2017;90:20160723. |
| 2. | Layden JE, Ghinai I, Pray I, Kimball A, Layer M, Tenforde M, et al. Pulmonary illness related to e-cigarette use in Illinois and Wisconsin - preliminary report. N Engl J Med [online ahead of print] 6 Sep 2019; DOI: 10.1056/NEJMoa1911614. |
| 3. | Henry TS, Kanne JP, Kligerman SJ. Imaging of vaping-associated lung disease. N Engl J Med 2019;381:1486–1487. |
| 4. | Triantafyllou GA, Tiberio PJ, Zou RH, Lamberty PE, Lynch MJ, Kreit JW, et al. Vaping-associated acute lung injury: a case series. Am J Respir Crit Care Med 2019;200:1430–1431. |
Author Contributions: M.A.L., N.A.J., and P.J.M. conceived of the project. All authors contributed to and approved the final manuscript. P.J.M. was the corresponding author of this manuscript and takes full responsibility for its contents.
Originally Published in Press as DOI: 10.1164/rccm.201909-1786IM on January 6, 2020
Author disclosures are available with the text of this article at www.atsjournals.org.
