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Case Reports in Pulmonology

Volume 2018, Article ID 9724530, 3 pages
https://doi.org/10.1155/2018/9724530

Case Report
Diffuse Alveolar Hemorrhage Induced by Vaping

Michael Agustin , Michele Yamamoto, Felix Cabrera, and Ricardo Eusebio

Guam Regional Medical City, 133 Route 3, Dededo, Guam 96929, USA

Correspondence should be addressed to Michael Agustin; [email protected]

Received 17 March 2018; Revised 22 April 2018; Accepted 24 April 2018; Published 7 June 2018

Academic Editor: Takeshi Terashima

Copyright © 2018 Michael Agustin et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

There has been a significant increase in electronic cigarette (e-cigarette) use since its introduction in 2007. Ironically, there remains
very few published literature on the respiratory complications of e-cigarettes. The use of personalized vaporizers or commonly
known as “vaping” has started to overtake standard e-cigarette. Its dynamic vaporizer customization makes it challenging to assess
long-term health effects. Case reports on the pulmonary complications of e-cigarettes are limited to bronchiectasis, eosinophilic
pneumonia, pleural effusion, and suspected hypersensitivity pneumonitis. Diffuse alveolar hemorrhage (DAH) is bleeding into
the alveolar spaces of the lung secondary to disruption of the alveolar-capillary basement membrane. We report a case of young
male presenting with subacute respiratory failure. He was later found to have diffuse alveolar hemorrhage syndrome that is likely
induced by aggressive vaping. This adds up to the rising concern on the possible serious complications of this innovative technology
designed as a safer alternative to traditional cigarettes.

1. Introduction 2. Case Presentation

Electronic cigarettes (e-cigarettes) were initially marketed in Thirty-three-year-old male with diabetes and seizure disor-
2007 and since then there had been a steady growth of its use der presented to the emergency department (ED) with wors-
amongst naive and chronic smokers [1]. “Vapor” is the aerosol ening dyspnea and hemoptysis. Two weeks prior to his ED
inhaled through heating a liquid in the device [2]. Nowadays, presentation, he was treated with antibiotics for community
personal vaporizers or “vape” are considered a step-up from acquired pneumonia with minimal improvement. Upon fur-
the standard e-cigarette. Its popularity is mainly driven by ther inquiry, patient admitted to vaping for the past 2 months
the ability for device customization. Users can mix and match with overtly increased exposure time and has experimented
liquids to achieve preferred flavor and cloud production. on new flavors. He denied previous or current recreational
To date, there still varied results on how e-cigarette affects drug use. CT scan of the chest showed diffuse ground glass
smoking cessation [3–5]. Whether or not the efficacy of e- opacities and bilateral patchy consolidation (Figure 1(a)). He
cigarettes for assisting smoking cessation becomes estab- had worsening hypoxia that required noninvasive ventilation.
lished, its safety profile and health related risks warrant His echocardiogram was otherwise normal. Bronchoscopic
extensive evaluation. The dynamic device design makes it examination failed to demonstrate airway lesions. Bron-
difficult to perform calculations of the harm compared with choalveolar lavage (BAL) revealed increasing blood in four
conventional cigarette smoking [6]. sequential aliquots confirming diagnosis of DAH (Figure 2).
There exists very few reported cases of pulmonary BAL cell count showed greater than 30,000 RBCs and 800
complications of e-cigarettes and these are limited to WBCs, 42% neutrophils, 36% lymphocytes, 1% eosinophils,
hypersensitivity inhalational injury, pneumonitis, and acute and 21% macrophages. All inflammatory serologies were
eosinophilic pneumonia [7]. We report a case of diffuse unremarkable: erythrocyte sedimentation rate (ESR), C-
alveolar hemorrhage that we believe was caused by aggressive reactive protein (CRP), rheumatoid factor (RF), antinu-
use of personalized vaporizer. This aims to site the serious clear antibody (ANA), and anti-antineutrophil cytoplasmic
complication of vaping despite being marketed as a safe antibodies (ANCA). In addition, serum eosinophil count,
substitute to conventional smoking. anti-glomerular basement membrane (GBM) antibodies, and
2 Case Reports in Pulmonology

(a) (b)

Figure 1: (a) Chest CT scan on admission with diffuse ground glass opacity and bilateral patchy consolidation. (b) Chest CT scan two weeks
after admission showing improvement of parenchymal lesions. Patient developed mild subcutaneous emphysema following right lung wedge
resection biopsy.

There are a few published reports on the respiratory

complications of e-cigarettes. These are limited to bronchiec-
tasis, eosinophilic pneumonia, pleural effusion, and sus-
pected hypersensitivity pneumonitis [7, 8]. Biopsy-proven
Respiratory Bronchiolitis Interstitial Lung Disease (RBILD)
has been demonstrated with e-cigarette use in one case report
[9]. Atypical pneumonitis evidenced by bronchoalveolar
lavage analysis and lipid staining has also been reported. The
syndrome of diffuse alveolar hemorrhage is caused by injury
or inflammation of the arterioles, venules, or alveolar capil-
Figure 2: Bronchoalveolar lavage (BAL) revealed increasing blood laries. DAH is often a catastrophic clinical syndrome causing
in four sequential aliquots confirming diagnosis of diffuse alveolar respiratory failure. The etiology of DAH is multifactorial
hemorrhage (DAH). and can be divided into three categories, namely, pulmonary
capillaritis, bland alveolar hemorrhage, and diffuse alveolar
damage (DAD) [10]. Recognition of DAH often requires BAL
analysis as symptoms are nonspecific. Hemoptysis is absent
anti-phospholipid antibodies were all normal. Urine toxicol- in up to one-third of patients, and radiographic imaging is
ogy screen which includes amphetamines, cannabinoids, and also nonspecific and similar to other acute alveolar filling
cocaine was negative. There was no microbiologic growth processes [10, 11]. Lung biopsy is often required to establish
on all BAL specimens. Patient was treated with pulse dose definite pathologic pattern.
steroids after DAH was confirmed with BAL aliquots (Fig- Cases relating to smoking-induced DAH are limited
ure 2). He underwent right wedge resection lung biopsy to few reports on cocaine and cannabis use [12, 13]. We
which revealed evidence of bland pulmonary hemorrhage postulate that direct exposure to inhalation products of
(Figure 3(a)) with no evidence of capillaritis or diffuse heated liquid resulted to alveolar injury. The exposure may or
alveolar damage (DAD). Prussian blue iron staining was may not elicit alveolar inflammation. Although cell culture
also noted which reflects old hemorrhage (Figure 3(b)). His and experimental animal data indicate that e-cigarette have
symptoms improved with complete resolution of alveolar the potential for inducing inflammation, this still remains
hemorrhage on chest CT scan after 2 weeks (Figure 1(b)). His unclear on human studies [14]. The e-juice used in this case
steroids were tapered quickly and he has not used a personal had a predominant base of propylene glycol (PG) in addition
vaporizer since then. to nicotine, water, and 2 artificial flavorings. The temporal
relations of patient’s aggressive vaping and the development
3. Discussion of alveolar hemorrhage remain circumstantial. However, we
are unaware of any other explanation for the patient’s bland
The use of personalized vaporizers or vaping has expo- pulmonary hemorrhage. Cessation of implicated exposure
nentially increased replacing standard e-cigarettes. It has and supportive care are core treatments of DAH. Immuno-
attracted young adults as they can customize and reuse their suppressive medication is added if there is histologic evidence
vaporizers making it a cheaper alternative. While vaping is of capillaritis. In our case, it is challenging to determine if
likely less toxic than cigarette smoking given the lack of most the improvement of patient’s symptoms and radiographic
combustible tobacco constituents, we are still uncertain on findings were related to discontinuation of exposure to vapor
the health hazards of the reduced toxins. The rapidly changing or the effect of steroids. Pulse steroids were initiated early
designs of the product and the lack of long-term follow-up in our patient as his hypoxia continued to worsen. This was
make assessment on the risk of health challenging [6]. tapered quickly as soon as inflammatory makers showed
Case Reports in Pulmonology 3

(a) (b)

Figure 3: (a) Lung biopsy showing alveolar hemorrhage. (b) Prussian blue iron staining reflecting old hemorrhage.

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lung disease secondary to electronic nicotine delivery system
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Conflicts of Interest [12] F. Grassin, M. André, B. Rallec, E. Combes, U. Vinsonneau,
and N. Paleiron, “Hémorragie alvéolaire fatale après bang
The authors declare that there are no conflicts of interest de cannabisFatal alveolar haemorrhage following a “bang” of
regarding the publication of this paper. cannabis,” Revue des Maladies Respiratoires, vol. 28, no. 7, pp.
919–923, 2011.
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