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Doctors warn of potential dangers of e-cigarettes

‘Catastrophic’ hypersensitivity pneumonitis occurred in teen who had recently switched from cigarettes to vaping

Louise Prime

Wednesday, 13 November 2019

Doctors have warned that we “consider e-cigarettes as ‘much safer than tobacco’ at our peril”, after they reported a case of a teenaged boy who presented with “catastrophic” life-threatening hypersensitivity pneumonitis after he switched from smoking conventional cigarettes to vaping, thought to be an exaggerated immune response to one of the chemicals in the vaping fluid. They also urged other clinicians to consider this possible diagnosis in anyone presenting with an atypical respiratory illness.

In their report*, published in Archives of Disease in Childhood, the doctors from Nottingham University Hospitals NHS Trust said the previously healthy 16-year-old boy, with no confirmed diagnosis of asthma, had presented in A&E after a week of fever, cough and increasing difficulty breathing despite oral antibiotics and inhaled salbutamol. He told them he had recently started to use e-cigarettes fairly frequently, using two different vaping liquids that he had bought over the counter – with identical ingredients apart from two unnamed flavourings.

The doctors reported that after rapid deterioration the boy needed non-invasive, conventional and then high-frequency oscillation ventilation; after developing intractable respiratory failure he had to be transferred for extracorporeal membrane oxygenation (ECMO). He had three days of venovenous ECMO and treatment with broad-spectrum intravenous antibiotics, intravenous hydrocortisone, a macrolide and antifungals. Ten days after admission he was able to be stepped down to the paediatric respiratory ward on 4 litres/min nasal cannula oxygen, with inhaled bronchodilators and oral corticosteroids for a putative diagnosis of asthma. However, he developed a critical illness and steroid myopathy and required prolonged rehabilitation.

At 35 days after admission he was discharged home with a plan to slowly taper oral steroids, but worsening respiratory status meant he returned to the emergency department on one occasion and was admitted on another requiring intensive treatment for respiratory distress and wheeze; he insisted he had not used any more e-cigarettes.

The report’s authors commented that the patient meets the diagnostic criteria for hypersensitivity pneumonitis secondary to e-cigarettes – “with a positive exposure history, deterioration after skin prick testing, specific serum IgM antibodies against the implicated liquid raising the possibility that the relevant antigen was present in that liquid and radiological and histopathological features compatible with acute HP”.

They concluded that there are two learning points from this case: “The first is always to consider a reaction to e-cigarettes in someone presenting with an atypical respiratory illness. The second is that we consider e-cigarettes as ‘much safer than tobacco’ at our peril.”

The boy, Ewan Fisher, told the BBC yesterday that the event occurred in May 2017. He said: “I thought I was going to die… I’m still not back to normal, I’d say 75-80%, it’s in the last six months that I’m feeling a bit stronger in myself. Vaping has basically ruined me… Is it worth risking your life for smoking e-cigs?”

Dr Hemant Kulkarni, consultant in paediatric respiratory medicine at Sheffield Children’s NHS Foundation Trust, also commented to BBC News: “As vaping becomes more popular, we are beginning to see more cases. Some of the cases my colleagues and I have seen are teenagers presenting with severe lung injury and some of these have been life-threatening. However, in the cases I’ve been involved in, patients are now regaining normal lung function.”

He added that he is “surprised” that e-cigarettes are advertised in the UK, given the lack of scientific studies on their safety.

*Nair N, Hurley M, Gates S, et al. Life-threatening hypersensitivity pneumonitis secondary to e-cigarettes. Archives of Disease in Childhood. Published Online First: 11 November 2019. doi: 10.1136/archdischild-2019-317889

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