Vitamin E Acetate in Bronchoalveolar-Lavage Fluid Associated with EVALI

doi:10.1056/NEJMoa1916433

. 2020 Feb 20;382(8):697-705.

doi: 10.1056/NEJMoa1916433. Epub 2019 Dec 20.

Vitamin E Acetate in Bronchoalveolar-Lavage Fluid Associated with EVALI

Benjamin C Blount¹, Mateusz P Karwowski¹, Peter G Shields¹, Maria Morel-Espinosa¹, Liza Valentin-Blasini¹, Michael Gardner¹, Martha Braselton¹, Christina R Brosius¹, Kevin T Caron¹, David Chambers¹, Joseph Corstvet¹, Elizabeth Cowan¹, Víctor R De Jesús¹, Paul Espinosa¹, Carolina Fernandez¹, Cory Holder¹, Zsuzsanna Kuklenyik¹, Jennifer D Kusovschi¹, Cody Newman¹, Gregory B Reis¹, Jon Rees¹, Chris Reese¹, Lalith Silva¹, Tiffany Seyler¹, Min-Ae Song¹, Connie Sosnoff¹, Carleen R Spitzer¹, Denise Tevis¹, Lanqing Wang¹, Cliff Watson¹, Mark D Wewers¹, Baoyun Xia¹, Douglas T Heitkemper¹, Isaac Ghinai¹, Jennifer Layden¹, Peter Briss¹, Brian A King¹, Lisa J Delaney¹, Christopher M Jones¹, Grant T Baldwin¹, Anita Patel¹, Dana Meaney-Delman¹, Dale Rose¹, Vikram Krishnasamy¹, John R Barr¹, Jerry Thomas¹, James L Pirkle¹; Lung Injury Response Laboratory Working Group

Collaborators, Affiliations

Collaborators

Lung Injury Response Laboratory Working Group:
Kathleen Attfield, Robert J Blount, Theodore M Brasky, Bobby N Brewer, Emily M Carlson, Kevin Chatham-Stephens, Sascha Ellington, Mary E Evans, Jeff Fowles, Jennifer Freed, Jo L Fruedenheim, Tiana Galindo, Macarena Garcia, Althea Grant, Donald Hayes, Amy Heinzerling, Tara C Jatlaoui, Rudolph Johnson, Joseph G Lisko, Matthew J Lozier, Ruth Lynfield, Joseph P McElroy, Paul Melstrom, Christina Mikosz, Wellington Onyenwe, Ian Pray, Sarah Reagan-Steiner, Sarah A Reisinger, Matthew D Ritchey, Mike Rollins, Chariety Sapp, Stephen D Soroka, Noel Stanton, Daniel Y Weng, Ian Williams, Jennifer Wiltz, Aaron Adams, Rayaj Ahamed, Kelly Ally, Stephen Arnstein, Doris Ash, Thomas Blake, William Bragg, Roberto Bravo, Melissa Carter, Charles Chambers, Abbey Doyle, Ryan Favors, Nathalie Gonzalez-Jimenez, Naudia Gray, Tonya Guillot, Beth Hamelin, Bryan Hearn, Alan Holder, Sam Isenberg, Leslie Jarchow, Ashley Jones, Logan Krajewski, Cassandra Kendall-Kyle, Erica Lewis, Howard Liverance, Ernest McGahee, Megan McGuigan, Magaly Mendez, Mike Mojica, Stephanie Negrete, Karen Rivera Nieves, Nick Pahno, Richard Steve Pappas, Jose Perez, Chris Pittman, Andrew Puetz, Sina De Leon Salazar, Rebecca Shaner, Karen Shields, Mitchell Smith, Tonya Tuberville, Hubert Vesper, Erin Wade, Rebekah Warton, Amy Watson, Andrew Wilmore, Joe Wooten, Stephanie Kerr, Alberto Santana, Shannon Woodward, Nicole Elliott, Michelle O'Hegarty, Josh Petty, Megan O'Sullivan, Sarah Kabbani, Stefanie Erskine, Susan Hocevar Adkins, Karen Hunter, Ibad Khan, Joann Kang, Emily H Koumans, Michele Montandon, David Weissman, Appathurai Balamurugan, Brandy Sutphin, James Allison, Gary Wheeler, Scott Becker, Eric Blank, Julianne Nassif, Kayla Thomas, Alon Volner, Julian Perez, Diane Noel, Sydney Jones, Katherine A Kelley, Matt Charles, Carlos Morales, Mohammad S Nasir, Charles Clark, Brian Pope, Nicolas Epie, Eric Hawkins, Sandeep Chowdhary, Dixie Harris, Nicole Green, David Blythe, Kenneth Feder, Cliff Mitchell, Matt Bashore, Rita Seith, Eden Wells, Cory Cole, Paige D'Heilly, Kaila Hanson, Stacy Holzbauer, Mark Lunda, Jason Peterson, Stefan Saravia, Terra Wiens, Matt Wogen, George Turabelidze, Valerie Howard, Kristy Michie, Russ Bowler, Kate Koehler, Lorene Vanzandt, Emily Hall, Varun Shetty, Branden Ainsworth, Jordan Green, Rodney Goller, Jackie Patel, Duane Satzger, Rachael Schmidt, Alejandro Comellas, David Spink, Shannon McBee, Lindsay Barr, Christy Reed, Meshel Lange, Jon Meiman

Affiliation

¹ From the Division of Laboratory Sciences, National Center for Environmental Health (B.C.B., M.P.K., M.M.-E., L.V.-B., M.G., M.B., C.R.B., K.T.C., D.C., J.C., E.C., V.R.D.J., P.E., C.F., C.H., Z.K., J.D.K., C.N., G.B.R., J.R., C.R., L.S., T.S., C.S., D.T., L.W., C.W., B.X., J.R.B., J.T., J.L.P.), Epidemic Intelligence Service, Center for Surveillance, Epidemiology, and Laboratory Sciences (I.G.), the Office of the Director (P.B.) and the Office on Smoking and Health (B.A.K.), National Center for Chronic Disease Prevention and Health Promotion, the Office of the Director, National Institute for Occupational Safety and Health (L.J.D.), the Office of Strategy and Innovation (C.M.J.) and the Division of Overdose Prevention (G.T.B.), National Center for Injury Prevention and Control, the Office of the Director, National Center for Immunization and Respiratory Diseases (A.P.), the Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities (D.M.D.), the Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infectious Diseases (D.R.), and the Office of the Director, National Center for Injury Prevention and Control (V.K.) - all at the Centers for Disease Control and Prevention, Atlanta; the Comprehensive Cancer Center, Ohio State University and James Cancer Hospital (P.G.S.), and the Division of Environmental Health Science, College of Public Health (M.-A.S.), and Pulmonary and Critical Care Medicine, Department of Internal Medicine (C.R.S., M.D.W.), Ohio State University, Columbus; the Food and Drug Administration, Silver Spring, MD (D.T.H.); and the Illinois Department of Public Health, Chicago (I.G., J.L.).

PMID: 31860793
PMCID: PMC7032996
DOI: 10.1056/NEJMoa1916433

Vitamin E Acetate in Bronchoalveolar-Lavage Fluid Associated with EVALI

Benjamin C Blount et al. N Engl J Med. 2020.

. 2020 Feb 20;382(8):697-705.

doi: 10.1056/NEJMoa1916433. Epub 2019 Dec 20.

Authors

Collaborators

Lung Injury Response Laboratory Working Group:
Kathleen Attfield, Robert J Blount, Theodore M Brasky, Bobby N Brewer, Emily M Carlson, Kevin Chatham-Stephens, Sascha Ellington, Mary E Evans, Jeff Fowles, Jennifer Freed, Jo L Fruedenheim, Tiana Galindo, Macarena Garcia, Althea Grant, Donald Hayes, Amy Heinzerling, Tara C Jatlaoui, Rudolph Johnson, Joseph G Lisko, Matthew J Lozier, Ruth Lynfield, Joseph P McElroy, Paul Melstrom, Christina Mikosz, Wellington Onyenwe, Ian Pray, Sarah Reagan-Steiner, Sarah A Reisinger, Matthew D Ritchey, Mike Rollins, Chariety Sapp, Stephen D Soroka, Noel Stanton, Daniel Y Weng, Ian Williams, Jennifer Wiltz, Aaron Adams, Rayaj Ahamed, Kelly Ally, Stephen Arnstein, Doris Ash, Thomas Blake, William Bragg, Roberto Bravo, Melissa Carter, Charles Chambers, Abbey Doyle, Ryan Favors, Nathalie Gonzalez-Jimenez, Naudia Gray, Tonya Guillot, Beth Hamelin, Bryan Hearn, Alan Holder, Sam Isenberg, Leslie Jarchow, Ashley Jones, Logan Krajewski, Cassandra Kendall-Kyle, Erica Lewis, Howard Liverance, Ernest McGahee, Megan McGuigan, Magaly Mendez, Mike Mojica, Stephanie Negrete, Karen Rivera Nieves, Nick Pahno, Richard Steve Pappas, Jose Perez, Chris Pittman, Andrew Puetz, Sina De Leon Salazar, Rebecca Shaner, Karen Shields, Mitchell Smith, Tonya Tuberville, Hubert Vesper, Erin Wade, Rebekah Warton, Amy Watson, Andrew Wilmore, Joe Wooten, Stephanie Kerr, Alberto Santana, Shannon Woodward, Nicole Elliott, Michelle O'Hegarty, Josh Petty, Megan O'Sullivan, Sarah Kabbani, Stefanie Erskine, Susan Hocevar Adkins, Karen Hunter, Ibad Khan, Joann Kang, Emily H Koumans, Michele Montandon, David Weissman, Appathurai Balamurugan, Brandy Sutphin, James Allison, Gary Wheeler, Scott Becker, Eric Blank, Julianne Nassif, Kayla Thomas, Alon Volner, Julian Perez, Diane Noel, Sydney Jones, Katherine A Kelley, Matt Charles, Carlos Morales, Mohammad S Nasir, Charles Clark, Brian Pope, Nicolas Epie, Eric Hawkins, Sandeep Chowdhary, Dixie Harris, Nicole Green, David Blythe, Kenneth Feder, Cliff Mitchell, Matt Bashore, Rita Seith, Eden Wells, Cory Cole, Paige D'Heilly, Kaila Hanson, Stacy Holzbauer, Mark Lunda, Jason Peterson, Stefan Saravia, Terra Wiens, Matt Wogen, George Turabelidze, Valerie Howard, Kristy Michie, Russ Bowler, Kate Koehler, Lorene Vanzandt, Emily Hall, Varun Shetty, Branden Ainsworth, Jordan Green, Rodney Goller, Jackie Patel, Duane Satzger, Rachael Schmidt, Alejandro Comellas, David Spink, Shannon McBee, Lindsay Barr, Christy Reed, Meshel Lange, Jon Meiman

Affiliation

¹ From the Division of Laboratory Sciences, National Center for Environmental Health (B.C.B., M.P.K., M.M.-E., L.V.-B., M.G., M.B., C.R.B., K.T.C., D.C., J.C., E.C., V.R.D.J., P.E., C.F., C.H., Z.K., J.D.K., C.N., G.B.R., J.R., C.R., L.S., T.S., C.S., D.T., L.W., C.W., B.X., J.R.B., J.T., J.L.P.), Epidemic Intelligence Service, Center for Surveillance, Epidemiology, and Laboratory Sciences (I.G.), the Office of the Director (P.B.) and the Office on Smoking and Health (B.A.K.), National Center for Chronic Disease Prevention and Health Promotion, the Office of the Director, National Institute for Occupational Safety and Health (L.J.D.), the Office of Strategy and Innovation (C.M.J.) and the Division of Overdose Prevention (G.T.B.), National Center for Injury Prevention and Control, the Office of the Director, National Center for Immunization and Respiratory Diseases (A.P.), the Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities (D.M.D.), the Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infectious Diseases (D.R.), and the Office of the Director, National Center for Injury Prevention and Control (V.K.) - all at the Centers for Disease Control and Prevention, Atlanta; the Comprehensive Cancer Center, Ohio State University and James Cancer Hospital (P.G.S.), and the Division of Environmental Health Science, College of Public Health (M.-A.S.), and Pulmonary and Critical Care Medicine, Department of Internal Medicine (C.R.S., M.D.W.), Ohio State University, Columbus; the Food and Drug Administration, Silver Spring, MD (D.T.H.); and the Illinois Department of Public Health, Chicago (I.G., J.L.).

PMID: 31860793
PMCID: PMC7032996
DOI: 10.1056/NEJMoa1916433

Abstract

Background: The causative agents for the current national outbreak of electronic-cigarette, or vaping, product use-associated lung injury (EVALI) have not been established. Detection of toxicants in bronchoalveolar-lavage (BAL) fluid from patients with EVALI can provide direct information on exposure within the lung.

Methods: BAL fluids were collected from 51 patients with EVALI in 16 states and from 99 healthy participants who were part of an ongoing study of smoking involving nonsmokers, exclusive users of e-cigarettes or vaping products, and exclusive cigarette smokers that was initiated in 2015. Using the BAL fluid, we performed isotope dilution mass spectrometry to measure several priority toxicants: vitamin E acetate, plant oils, medium-chain triglyceride oil, coconut oil, petroleum distillates, and diluent terpenes.

Results: State and local health departments assigned EVALI case status as confirmed for 25 patients and as probable for 26 patients. Vitamin E acetate was identified in BAL fluid obtained from 48 of 51 case patients (94%) in 16 states but not in such fluid obtained from the healthy comparator group. No other priority toxicants were found in BAL fluid from the case patients or the comparator group, except for coconut oil and limonene, which were found in 1 patient each. Among the case patients for whom laboratory or epidemiologic data were available, 47 of 50 (94%) had detectable tetrahydrocannabinol (THC) or its metabolites in BAL fluid or had reported vaping THC products in the 90 days before the onset of illness. Nicotine or its metabolites were detected in 30 of 47 of the case patients (64%).

Conclusions: Vitamin E acetate was associated with EVALI in a convenience sample of 51 patients in 16 states across the United States. (Funded by the National Cancer Institute and others.).

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Comment in

Cornering the Suspects in Vaping-Associated EVALI.
Gordon T, Fine J. Gordon T, et al. N Engl J Med. 2020 Feb 20;382(8):755-756. doi: 10.1056/NEJMe2001065. N Engl J Med. 2020. PMID: 32074424 No abstract available.

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References

1. Centers for Disease Control and Prevention. Outbreak of lung injury associated with e-cigarette use, or vaping. December 12, 2019. (https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-d...).
1. Siegel DA, Jatlaoui TC, Koumans EH, et al. Update: interim guidance for health care providers evaluating and caring for patients with suspected e-cigarette, or vaping, product use associated lung Injury — United States, October 2019. Am J Transplant 2019;19:3420–8. - PMC - PubMed
1. Lozier MJ, Wallace B, Anderson K, et al. Update: demographic, product, and sub-stance-use characteristics of hospitalized patients in a nationwide outbreak of e-cigarette, or vaping, product use-associated lung injuries — United States, December 2019. MMWR Morb Mortal Wkly Rep 2019;68:1142–8. - PMC - PubMed
1. Henry TS, Kligerman SJ, Raptis CA, Mann H, Sechrist JW, Kanne JP. Imaging findings of vaping-associated lung injury. AJR Am J Roentgenol 2019. October 8 (Epub ahead of print). - PubMed
1. Butt YM, Smith ML, Tazelaar HD, et al. Pathology of vaping-associated lung injury. N Engl J Med 2019;381:1780–1. - PubMed

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[1] Centers for Disease Control and Prevention. Outbreak of lung injury associated with e-cigarette use, or vaping. December 12, 2019. (https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-d...).

[2] Centers for Disease Control and Prevention. Outbreak of lung injury associated with e-cigarette use, or vaping. December 12, 2019. (https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-d...).

[3] Siegel DA, Jatlaoui TC, Koumans EH, et al. Update: interim guidance for health care providers evaluating and caring for patients with suspected e-cigarette, or vaping, product use associated lung Injury — United States, October 2019. Am J Transplant 2019;19:3420–8. - PMC - PubMed

[4] Siegel DA, Jatlaoui TC, Koumans EH, et al. Update: interim guidance for health care providers evaluating and caring for patients with suspected e-cigarette, or vaping, product use associated lung Injury — United States, October 2019. Am J Transplant 2019;19:3420–8. - PMC - PubMed

[5] Lozier MJ, Wallace B, Anderson K, et al. Update: demographic, product, and sub-stance-use characteristics of hospitalized patients in a nationwide outbreak of e-cigarette, or vaping, product use-associated lung injuries — United States, December 2019. MMWR Morb Mortal Wkly Rep 2019;68:1142–8. - PMC - PubMed

[6] Lozier MJ, Wallace B, Anderson K, et al. Update: demographic, product, and sub-stance-use characteristics of hospitalized patients in a nationwide outbreak of e-cigarette, or vaping, product use-associated lung injuries — United States, December 2019. MMWR Morb Mortal Wkly Rep 2019;68:1142–8. - PMC - PubMed

[7] Henry TS, Kligerman SJ, Raptis CA, Mann H, Sechrist JW, Kanne JP. Imaging findings of vaping-associated lung injury. AJR Am J Roentgenol 2019. October 8 (Epub ahead of print). - PubMed

[8] Henry TS, Kligerman SJ, Raptis CA, Mann H, Sechrist JW, Kanne JP. Imaging findings of vaping-associated lung injury. AJR Am J Roentgenol 2019. October 8 (Epub ahead of print). - PubMed

[9] Butt YM, Smith ML, Tazelaar HD, et al. Pathology of vaping-associated lung injury. N Engl J Med 2019;381:1780–1. - PubMed

[10] Butt YM, Smith ML, Tazelaar HD, et al. Pathology of vaping-associated lung injury. N Engl J Med 2019;381:1780–1. - PubMed

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Vitamin E Acetate in Bronchoalveolar-Lavage Fluid Associated with EVALI

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Vitamin E Acetate in Bronchoalveolar-Lavage Fluid Associated with EVALI

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