Vitamin E Acetate in Bronchoalveolar-Lavage Fluid Associated with EVALI

Benjamin C Blount, Mateusz P Karwowski, Peter G Shields, Maria Morel-Espinosa, Liza Valentin-Blasini, Michael Gardner, Martha Braselton, Christina R Brosius, Kevin T Caron, David Chambers, Joseph Corstvet, Elizabeth Cowan, Víctor R De Jesús, Paul Espinosa, Carolina Fernandez, Cory Holder, Zsuzsanna Kuklenyik, Jennifer D Kusovschi, Cody Newman, Gregory B Reis, Jon Rees, Chris Reese, Lalith Silva, Tiffany Seyler, Min-Ae Song, Connie Sosnoff, Carleen R Spitzer, Denise Tevis, Lanqing Wang, Cliff Watson, Mark D Wewers, Baoyun Xia, Douglas T Heitkemper, Isaac Ghinai, Jennifer Layden, Peter Briss, Brian A King, Lisa J Delaney, Christopher M Jones, Grant T Baldwin, Anita Patel, Dana Meaney-Delman, Dale Rose, Vikram Krishnasamy, John R Barr, Jerry Thomas, James L Pirkle
New England Journal of Medicine 2020 February 20, 382 (8): 697-705

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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