PC1141: Rare Partners in Crime: E-cigarette or Vaping Use Associated Lung Injury and Pneumocystis Pneumonia

Introduction: Physicians throughout the country are looking for ways to combat the increasing epidemic known as vaping (e-cigarette). Vape fumes contain fine particulates of toxic chemicals that have recently been liked to cardiopulmonary diseases. E-cigarette use has been known to impair respiratory innate immune cell function such as impairment of neutrophil chemotaxis and phagocytosis, eventually increasing susceptibility to atypical infections. We present a case of vaping related incidence of Pneumocystis jirovecii (PJP) infection.

Case Description: A 17-year-old Caucasian male presented to the emergency department with concerns of shortness of breath, difficulty breathing and productive cough for 2 weeks. He endorsed daily vaping and marijuana use for the past 4 years. Within hours of presentation, his respiratory status deteriorated requiring emergent intubation and ventilatory support. Initial chest x-ray showed diffuse bilateral ground glass appearance and inflammation (Figure 1). CT angiogram revealed multifocal ground glass opacities and consolidative processes concerning for viral pneumonia (Figure 2). Given the acute worsening of respiratory failure, the pulmonary team recommended bronchoscopy with bronchoalveolar lavage (BAL). The staining of BAL was positive for Pneumocystis jirovecii. Further autoimmune work up was negative. He was subsequently diagnosed with a case of e-cigarette or vaping product use associated lung injury (EVALI) with concurrent Pneumocystis pneumonia. Patient was started on a 21-day course of Trimethoprim-sulfamethoxazole for his PJP pneumonia. Patient started to show significant overall improvement clinically and functional capacity.

Discussion: After ruling out all other possible etiologies for this patient’s acute respiratory failure and with the presence of a significant exposure to e-cigarette use, the patient had a probable case of EVALI. This was further verified by the presence of lipid laden macrophages in the BAL and the rapid improvement on high dose steroids. The superimposed Pneumocystis pneumonia infection underscores the hazardous effects of e-cigarettes on the local pulmonary immune system.

It is believed that the aerosolized particles from vaping get deposited within the distal airways and alveoli, leading to a local inflammatory response mediated by production of reactive oxygen species and inflammatory cytokines. Inflammation and subsequent fibrosis impairs the gas exchange at alveolar level. In addition, there is significant inhibition of phagocytosis which would further impair bacterial clearance in the lungs. This impaired bacterial clearance can lead to colonization of opportunistic microorganisms such as Pneumocystis jirovecii.

Conclusion: Within literature review, it appears there is no prior documented association between EVALI and PJP in an otherwise apparently immunocompetent young adult. The patient’s personal or family history did not suggest inborn metabolism errors causing immunodeficiency. This case reminds us of the severity and potentially deadly complications of the epidemic that is vaping. As physicians, having a high degree of suspicion for EVALI and/or superimposed infections can help with early detection and timely management of such patients.