A 23-year-old Man With Acute Lung Injury After Using a Tetrahydrocannabinol-containing Vaping Device

A Case Report

Anthony Lucero; Niklas Eriksson; Carli Nichta; Kimberly Sokol


J Med Case Reports. 2021;15(70) 

In This Article


THC-containing vaping products have very recently become more widely available for consumption, which was helped in part by the legalization of marijuana for either recreational or medical use by the majority of states in the United States.[8] There have subsequently been many identified cases of respiratory distress and lung injury in patients with recent vaping product use. These were first described and identified by the CDC in 2019, with 68 deaths reported thus far.[1] The mechanism of injury in acute lung injury after vaping remains poorly understood. A study in Belgium has shown that the propylene glycol and glycerol in vaping devices may be associated with decreased gas exchange and airway epithelial injury and that this injury pattern is not associated with nicotine.[6] Other recent literature suggests additives such as vitamin E acetate, diacetyl, and methanol in vaping products also may be implicated in this pattern of lung injury.[4,5] It is extremely difficult to make the diagnosis of VALI because there are no readily available tests to confirm the presence of the disease. Testing BAL samples for vitamin E acetate, diacetyl, methanol are not available in most conventional laboratories, and the aforementioned studies identifying these compounds were performed in a CDC laboratory. One case report suggests that lipid-laden macrophages in BAL fluid samples may suggest VALI.[9] Another study of eight males with respiratory symptoms after vaping showed chest imaging findings of diffuse ground-glass opacities in all patients; however, this finding is not specific for VALI.[10] Diagnosis is supported mainly by recent (within 90 days) use of a vaping product; diffuse lung opacities visualized by radiography; exclusion of lung infection by sputum cultures, blood cultures, BAL, or other diagnostic criteria; and the absence of a likely alternative diagnosis.[11,12] Given that our patient was young and immunocompetent, the likelihood that his presentation was due to an overwhelming rhinovirus or enterovirus pneumonia was very low.[13] It is important for physicians to remember that VALI is a diagnosis of exclusion and that they should manage these patients just as they would any other patient presenting with dyspnea: by using supportive care with oxygen therapy or other respiratory care management, administering fluids, and ruling out other life-threatening causes of dyspnea.

Once the diagnosis of VALI is highly suspected, it is important for physicians to remember just how potentially life-threatening the disease process is. Approximately 95% of patients presenting with VALI have required hospitalization.[1] Aside from supplemental oxygen, systemic glucocorticoids have been used to treat these patients; however, the efficacy has yet to be formally studied.[9,14] Patients with respiratory failure or worsening respiratory status despite aggressive oxygen therapy may require intubation and/or ICU monitoring. Patients can only be considered for outpatient management if they do not have hypoxia (< 95%) on room air and have no signs of respiratory distress, no significant medical comorbidities that can contribute to worsening respiratory distress, and a strong social support system with close outpatient follow-up available.[1]