Scheduled maintenance
On June 16, 9pm EST, I took over the @Pathologists Twitter handle to host a Twitter discussion about what pathologists need to know about E-cigarette or Vaping Product Use-Associated Lung Injury (EVALI).
I also participated as a panelist under my Twitter handle (@YasmeenButtMD), and was joined by leading pulmonary pathologists Timothy Allen, MD, JD, FCAP (@TimAllenMDJD) and Sanjay Mukhopadhyay (@smlungpathguy).
Below are some highlights from the hour-long discussion.
#CAPchat Does lung injury due to vaping showing characteristic histologic change? https://t.co/PXX4PNxabP
— Dr. Bui Pathologist🌼 (@DrBuiPathology) June 17, 2020
Typically a transbronchial lung biopsy (see study below) or BAL. The role of either one is quite limited, as we will discuss, and neither is required for the diagnosis. #Capchat #pathology #pulmpath https://t.co/j5HN6JguVJ
— Sanjay Mukhopadhyay (@smlungpathguy) June 17, 2020
The pathology of vaping is acute lung injury (OP or DAD), which is not specific at all. #Capchat https://t.co/j5HN6JguVJ
— Sanjay Mukhopadhyay (@smlungpathguy) June 17, 2020
The findings are all nonspecific and must be the diagnosis must be reached in a multidisciplinary fashion together with clinical history. Other causes, particularly infection, must be ruled out! #capchat https://t.co/hKMOtDejPK
— Yasmeen M. Butt (@YasmeenButtMD) June 17, 2020
Q1: Is vaping dangerous? What’s your perspective when people say that this all just a hoax by the tobacco companies to make more people smoke cigarettes? #capchat
— CAPathologists (@Pathologists) June 17, 2020
A1: In short, for some people, YES – it can be quite dangerous and even deadly. #capchat
— Yasmeen M. Butt (@YasmeenButtMD) June 17, 2020
Yet it's complicated. Many vape for years with no obvious problem.#capchat https://t.co/wvfnekPbLA
— Timothy Craig Allen (@TimAllenMDJD) June 17, 2020
A1. Yes it’s dangerous, not a hoax. It does seem, however, that the strongest evidence of danger is for people who vaped illicit THC tainted with (illicit) vitamin E acetate. #Capchat #pathology #pulmpath #vaping #EVALI
— Sanjay Mukhopadhyay (@smlungpathguy) June 17, 2020
The vast majority of serious cases#capchat https://t.co/LzZ1fp6Aoz
— Timothy Craig Allen (@TimAllenMDJD) June 17, 2020
Absolutely true. 100% true. Whether regular nicotine vaping from legitimate store bought vapes is dangerous or not is not well known, and needs a lot more study. If it helps some established smokers people quit, the risk benefit ratio is worth examining. #Capchat
— Sanjay Mukhopadhyay (@smlungpathguy) June 17, 2020
Q1: I'm gonna be honest…I know very little about the social practice of vaping. Maybe someone can give a little primer on what exactly it is and how is it similar/different to cigarettes. #capchat
— Jason Scapa, MD (@JScapaPathMD) June 17, 2020
We have a review on Vaping for pathologists it includes a primer on what vaping is as well as a diagram of how a vaping device works #capchathttps://t.co/Rxqmu9vXYt
— Matthew Cecchini (@Path_Matt) June 17, 2020
#capchat to piggyback off this answer #Vaping is definitely a problem, #EVALI was seen everywhere for a few months likely in setting of Vit E acetate but the long term effects of Vaping, both nicotine and THC, not fully understood
— Sameer Khanijo (@KhanijoMD) June 17, 2020
#capchat Are people who vape at more risk for serious COVID-19 infections?
— Deepak Mohan, MD, FCAP, FASCP (@dmohanmd) June 17, 2020
Not that I know of! #Capchat
— Sanjay Mukhopadhyay (@smlungpathguy) June 17, 2020
Very interesting question there are some experimental models that show that vaping can interfere with the normal immune response in the lung https://t.co/iWNkprrW4f#capchat
— Matthew Cecchini (@Path_Matt) June 17, 2020
#capchat Have you seen any vaping cases with superimposed COVID infection, and what was the course of illness-
— Israh (K.)Akhtar (@israhkhan) June 17, 2020
I have not, but interestingly we have seen a small uptick in EVALI cases on our consult service in the past two months. #capchat Perhaps more people are bored and vaping in lock down?
— Yasmeen M. Butt (@YasmeenButtMD) June 17, 2020
#capchat Is it possible that the basic mechanism of vaping induced lung injury and COVID induced lung damage is same at the microenvironment?
— Israh (K.)Akhtar (@israhkhan) June 17, 2020
Interesting question! The end result can be very similar – acute lung injury! The body can respond in only so many ways. #capchat
— Yasmeen M. Butt (@YasmeenButtMD) June 17, 2020
#capchat Is it possible that the basic mechanism of vaping induced lung injury and COVID induced lung damage is same at the microenvironment?
— Israh (K.)Akhtar (@israhkhan) June 17, 2020
Yes, very similar! Both cause severe acute lung injury, same as
💥 drugs
💥 other bugs
💥 connective tissue disease
💥 aspiration
💥 other toxic inhalants #Capchat— Sanjay Mukhopadhyay (@smlungpathguy) June 17, 2020
And more! A very long list of differential diagnoses. Absolutely must correlate with clinical history and radiology prior to diagnosis.#capchat https://t.co/o7R5sY11QR
— Timothy Craig Allen (@TimAllenMDJD) June 17, 2020
#capchat I wonder if vaping will increase the risk of COVID-19 infection. https://t.co/VR62wFFruO
— Dr. Bui Pathologist🌼 (@DrBuiPathology) June 17, 2020
Q7: What is the differential for EVALI? #capchat
— CAPathologists (@Pathologists) June 17, 2020
A7: There is a broad differential for EVALI including infection, adverse drug reactions, and immune mediated processes among others. Essentially, anything that can cause acute lung injury. #capchat Clinical history is KEY.
— Yasmeen M. Butt (@YasmeenButtMD) June 17, 2020
A7.
💥 drug toxicity (amiodarone etc)
💥 other infections
💥 connective tissue disease
💥 aspiration
💥 other toxic inhalants
💥 sepsis
💥 acute exacerbation of ILD
💥 TRALI
💥 lung transplant related injury #Capchat— Sanjay Mukhopadhyay (@smlungpathguy) June 17, 2020
Thanks! Are the histological change due to vaping in long irreversible? #CAPchat https://t.co/WY9BkZrH2I
— Dr. Bui Pathologist🌼 (@DrBuiPathology) June 17, 2020
I have to say I’ve never seen a repeat biopsy in a vaping case, but the imaging abnormalities are reversible and some (many? most?) patients do recover completely after therapy and cessation of vaping . #Capchat #pathology #pulmpath
— Sanjay Mukhopadhyay (@smlungpathguy) June 17, 2020
The patients we have seen in follow up have had complete physical recovery (no need for supplemental O2), Improvements of CT scan, and normalizationof PFTs with the DLCO being last to return to normal #capchat #pulmcc #EVALI #Hypoxemia
— Sameer Khanijo (@KhanijoMD) June 17, 2020
@DrBuiPathology #capchat histologic findings in EVALI pic.twitter.com/ObmBrRuYz0
— Yasmeen M. Butt (@YasmeenButtMD) June 17, 2020
Most I think. But we are only beginning to study it.#capchat https://t.co/2GrbmnNpRG
— Timothy Craig Allen (@TimAllenMDJD) June 17, 2020
I imagine that a small percentage of the cases with diffuse alveolar damage (severe acute lung injury) will progress to fibrosis. #capchat #pulmpath https://t.co/EluJ60pPMN
— Yasmeen M. Butt (@YasmeenButtMD) June 17, 2020
Question: #capchat is the idea of "lipoid pneumonia" no longer valid in #EVALI and what do the lipid laden macrophages mean if anything? #pulmpath #pathologists @smlungpathguy @YasmeenButtMD
— Sameer Khanijo (@KhanijoMD) June 17, 2020
No. Nothing.#capchat https://t.co/z72KPFnvg5
— Timothy Craig Allen (@TimAllenMDJD) June 17, 2020
Lipid-laden macrophages (oil red O +) are frequently seen in infection, aspiration, drug reactions, and autoimmune disorders, often in high numbers! They are nonspecific findings. #capchat #pulmpath https://t.co/EPWz7dqEQu
— Yasmeen M. Butt (@YasmeenButtMD) June 17, 2020
A4. The histologic findings are acute lung injury: either organizing pneumonia or diffuse alveolar damage or some variant thereof. NOT lipoid pneumonia. #Capchat https://t.co/j5HN6JguVJ
— Sanjay Mukhopadhyay (@smlungpathguy) June 17, 2020
Q5: Acute lung injury is a term to describe several different patterns of injury (acute, as implied) including organizing pneumonia and diffuse alveolar damage (most severe form). #capchat https://t.co/2qZ5KGy3Vx
— Yasmeen M. Butt (@YasmeenButtMD) June 17, 2020
How often is oil red O even used anymore? 😬 #capchat https://t.co/dv4gzHOFDB
— mkintx (@mkintx1) June 17, 2020
Unfortunately, a fair amount now due to the misconceptions around EVALI. Anecdotally, we still see cases with oil red O being run to 'rule out' EVALI on our consult service. #capchat #pulmpath https://t.co/KzWp2nMyUr
— Yasmeen M. Butt (@YasmeenButtMD) June 17, 2020
Agree. Try to educate your clinicians of lack of utility, especially of the oil red O stain. #Capchat
— Sanjay Mukhopadhyay (@smlungpathguy) June 17, 2020
Do you see similar histologic findings in patients that do hookah or other inhaled vaporizing chemicals? #capchat
— Jason Scapa, MD (@JScapaPathMD) June 17, 2020
I am not sure but these vaping devices are capable of reaching very high temperatures between 110 and 1,008 °C and do not combust the products. This could lead to chemical reactions that do no occur in these other systems #capchat
— Matthew Cecchini (@Path_Matt) June 17, 2020
Indeed. There was an interesting case report on GIP developing in a vaping patient who was exposed to cobalt from the device. #capchat #pulmpath https://t.co/sfd8RH7RAH
— Yasmeen M. Butt (@YasmeenButtMD) June 17, 2020
Any specific/more common cytology features in bronchial wash/brushing/lavage described in literature which can be seen in #EVALI? #capchat
— Swikrity U Baskota,MD (@SwikrityUMD) June 17, 2020
Specific features? No. Macrophages have been reported, both foamy and ordinary (non foamy). Obviously, neither of these are specific for any diagnosis, including vaping #pathology #pulmpath #capchat
— Sanjay Mukhopadhyay (@smlungpathguy) June 17, 2020
W/ respect to macrophages , what’s the current theory on endogenous vs. exogenous lipids? Has anything changed in the past 6 months?
— Scott Padgett (@scottapadgett) June 17, 2020
No. All endogenous. Not a single documented cases of exogenous lipoid pneumonia due to vaping. All lung pathologists I know are united on this aspect. Vitamin E acetate yes, exogenous lipoid pneumonia no. #Capchat #pathology #pulmpath
— Sanjay Mukhopadhyay (@smlungpathguy) June 17, 2020
There’s a very good study on vitamin E acetate that everyone should read. Very strongly implicates vitamin E acetate. #Capchat https://t.co/zsoEDsHqEu
— Sanjay Mukhopadhyay (@smlungpathguy) June 17, 2020
For those that are interested there is also a very interesting paper that studies the chemistry behind how heating of vitamin E might lead to an acute lung injury #capchat https://t.co/S7HIOp9CiB
— Matthew Cecchini (@Path_Matt) June 17, 2020
Q: But the conclusion of this study is that Vitamin E acetate was found the lung of these patients. This does not mean that it is the cause of the disease. Is not obvious to find Vitamin E in the lungs if they are vaping it? Why other vapers has not the illness then? #capchat
— Mike Orville (@mikeorville85) June 17, 2020
There is clearly some type of susceptibility that some patients have to developing EVALI that others don't (as most people who vape don't develop EVALI). Unfortunately, we don't know what it is. #capchat https://t.co/CMjPBK9L35
— Yasmeen M. Butt (@YasmeenButtMD) June 17, 2020
We could speculate increased risk of infection. But again, there is no certainty. And there are many people who vape without problems. Focus IMHO should be on educating teens and young adults to not start vaping, or to stop. #ButPeerPressure #capchat https://t.co/peyBUqOSov
— Timothy Craig Allen (@TimAllenMDJD) June 17, 2020
Agreed. I think it's incumbent on the medical and #MedTwitter community to advocate for education of children/young adults and work towards #policy changes to make it harder for kids to vape and monitor advertising #flavors #capchat #EVALI #pulmonary #primarycare
— Sameer Khanijo (@KhanijoMD) June 17, 2020
The Hillsborough County Anti Drug Alliance is working with USF to develop educational materials/ presentations to prevent youth vaping and help those who already started to quit. We also advocate for sound tobacco policy. Thanks to all of you for up-to-date research and advice!
— ellen snelling (@LNseven5) June 17, 2020
Because their vapes didn’t contain vitamin E acetate. One of the tables in the study shows this well with adequate controls.
You are right presence of vitamin E acetate doesn’t prove causation but it’s very strong circumstantial evidence.
— Sanjay Mukhopadhyay (@smlungpathguy) June 17, 2020
Q14: Does finding vitamin E acetate mean that lipoid pneumonia really is the cause of EVALI? #capchat
— CAPathologists (@Pathologists) June 17, 2020
A14: Nope. It is likely the breakdown products of vitamin E acetate that are causing injury to the lungs rather than droplets of fat with vitamin E in them collecting in the lung. #capchat
— Yasmeen M. Butt (@YasmeenButtMD) June 17, 2020
We could speculate increased risk of infection. But again, there is no certainty. And there are many people who vape without problems. Focus IMHO should be on educating teens and young adults to not start vaping, or to stop. #ButPeerPressure #capchat https://t.co/peyBUqOSov
— Timothy Craig Allen (@TimAllenMDJD) June 17, 2020
#Capchat Any study on the effect of lung injury due to vaping in cancer patients?
— Dr. Bui Pathologist🌼 (@DrBuiPathology) June 17, 2020
I was going to ask if vaping has increased risk of certain pulmonary neoplasia like SCC or small cell. Also Head and Neck SCC? #capchat
— Jason Scapa, MD (@JScapaPathMD) June 17, 2020
Need studies; we are too early in our evaluation to say anything for certain. Also, it will require time to pass before we can evaluate for long-term lung injury#capchat https://t.co/fyQbrZoVlU
— Timothy Craig Allen (@TimAllenMDJD) June 17, 2020
Q10: Some pathologists report hearing that fat washes out in processing – doesn’t that mean pathologists can’t see it and then wouldn’t be able to diagnose lipoid pneumonia? #capchat
— CAPathologists (@Pathologists) June 17, 2020
A10: Nope! While fat does wash out in processing, it leaves holes behind. Just like if you cut an elephant out of a picture you would definitely recognize that there was an elephant there. #capchat
— Yasmeen M. Butt (@YasmeenButtMD) June 17, 2020
A10. Nope! This is such a basic fact in lung pathology that the question is laughable. In my opinion the whole misunderstanding comes from folks who have NEVER seen a single case of exogenous lipoid pneumonia in a lung biopsy. It’s distinctive! #Capchat
— Sanjay Mukhopadhyay (@smlungpathguy) June 17, 2020
Indeed! And yet, there is literally a publication out there stating this fact! I couldn't believe it. #capchat
— Yasmeen M. Butt (@YasmeenButtMD) June 17, 2020
Q3: True or False: only black market vapes are dangerous. #capchat
— CAPathologists (@Pathologists) June 17, 2020
A3: False. While the black or gray market vapes are more often implicated we have seen patients who use ‘legitimate’ vaping products become ill. #capchat
— Yasmeen M. Butt (@YasmeenButtMD) June 17, 2020
A3. This is tricky. The evidence for harm (acute lung injury) is strongest for THC vaping (which is the type associated with vitamin E acetate). Fewer cases have been reported in nicotine vapers, but veracity of history is a legitimate question #capchat
— Sanjay Mukhopadhyay (@smlungpathguy) June 17, 2020
Not "only" but appear to be the highest risk. Don't vape, but if one chooses to, absolutely avoid black market or other non-brand vaping products.#capchat https://t.co/QTJMpjk9rQ
— Timothy Craig Allen (@TimAllenMDJD) June 17, 2020
#capchatWe have 5 minutes remaining and I’d like to invite @TimAllenMDJD @smlungpathguy and @YasmeenButtMD to share any final thoughts they may have.
— CAPathologists (@Pathologists) June 17, 2020
Final thoughts:
💥 don’t vape if you are a child or teenager
🔥 if you don’t smoke don’t vape
✅ never vape from a bootlegged or illicit source
💥 The oil red O hysteria in vaping is completely bogus #Capchat— Sanjay Mukhopadhyay (@smlungpathguy) June 17, 2020
Vaping is a potentially dangerous activity, (and for some deadly) and certainly should not be used by people (especially young people) outside of being a medical tool for quitting traditional tobacco cigarettes. Diagnosis can be tricky – talk to your clinicians. Be safe! #capchat
— Yasmeen M. Butt (@YasmeenButtMD) June 17, 2020
Great discussion! Thank you @Pathologists for doing this! And @YasmeenButtMD for hosting! And @smlungpathguy for your wisdom! It was a privilege to participate.
The key to success is educating teens and young adults about the dangers of vaping. It is our charge.#capchat https://t.co/nMo57mQgCZ— Timothy Craig Allen (@TimAllenMDJD) June 17, 2020
Dr. Butt is a new-in-practice thoracic pathologist who is part of a busy pulmonary consultation service at Mayo Clinic Arizona. She is the author of numerous book chapters and articles in pulmonary pathology. She is a member of the CAP New In Practice and Digital Content Committees and a past member of the Resident Forum Executive Committee. She can be found on Twitter @YasmeenButtMD.
