The parents of Texas teen Tryson Zohfeld had no idea their son was using vaping products when he became desperately ill with an unexplained, rapidly progressing respiratory disease earlier this summer.
The 17-year-old presented at Fort Worth's Cook Children's Medical Center with abdominal pain, vomiting, and extreme difficulty breathing.
A battery of tests quickly ruled out infection, and lung biopsy and autoimmune testing also failed to find a cause for his lung failure.
"He had the million-dollar work-up, but we found nothing that could explain what was happening with him," Karen Schultz, MD, a pediatric pulmonologist at Cook Children's told 鶹ý.
On Tryson's third day in the hospital, his parents informed his still baffled doctors that they had learned he had been vaping heavily since the age of 14. Schultz was told he used a "variety of e-cigarette products," and she believes this caused his lungs to fail.
He is now recovering, but lost 30 pounds during his illness and required physical therapy after being bedridden for nearly three weeks.
"This was a very sick kid," Schultz said.
Zohfeld's case was one of hundreds around the country involving respiratory problems tied to vaping, or use of e-cigarettes. , the CDC confirmed 215 cases of severe lung illness among recent vapers in 25 states since June 28, as well as one death in Illinois. Another death is , and a Pennsylvania teenager with "vaping illness" symptoms is in a medically-induced coma.
While no official cause has been given, investigators have homed in on black-market cannabis or nicotine products, recently warning consumers to steer clear of them and to stop modifying these products at home. Michigan has become the first state to outright.
Physicians who have treated cases of vaping-related illness told 鶹ý that many patients reported vaping tetrahydrocannabinol (THC) oil, particularly from illicit sources.
Focus on 'Pot' Oil
No single substance or e-cigarette product has been consistently associated with the illness, but the CDC's recent warning noted that "many patients have reported using e-cigarettes containing cannabinoid products such as THC or CBD [cannabidiol]."
The patient who died in Oregon became sick after vaping THC from a product purchased at a recreational marijuana store, .
In Illinois, many, but not all, cases reported vaping black-market products containing THC oil.
"Not everyone reported using THC oil, but we can't say if that was because they were scared to acknowledge it or because they never used it," Ngozi Ezike, MD, director of the Illinois Department of Public Health (IDPH), told 鶹ý.
Scott Aberegg, MD, MPH, a pulmonologist at the University of Utah in Salt Lake City, who treated patients with vaping-related illness, also confirmed to 鶹ý that many of the cases presenting at his hospital reported vaping THC.
"Without discussing specific cases, I can say that as we are taking more detailed histories; our group and others are finding that THC (vaping) was used," he said. "It is speculation at this time, but certainly the substance causing these reactions is of great interest. And THC is high on the list of suspects."
Vaping black-market THC or CBD oil was implicated in a cluster of eight recent hospitalizations occurring in a single California county.
Marijuana sales, including THC- and CBD-oil products, are legal and regulated in Kings County, California, which has a population of around 150,000. But all eight of the respiratory cases reported in the recent cluster included patients who had purchased THC- or CBD-containing vaping cartridges from unlicensed "pop-up" retailers.
"These were long-time vapers who had recently switched to cheaper THC- or CBD- products purchased from unlicensed retailers," Nichole Fisher, RN, of Kings County Public Health Department, told 鶹ý.
Fisher said several samples of the black-market vaping products linked to the cases were recovered and have been sent to officials for analysis.
Anne Griffith, MD, a pediatric pulmonologist at Children's Respiratory and Critical Care Specialists in Minneapolis, agreed that evidence from her center continues to suggest vaping THC oil, which is often purchased over the internet, is playing a key role in the illnesses.
Children's Minnesota hospital network has now reported 10 confirmed and four suspected cases of severe respiratory distress with a suspected vaping cause. The cases ranged in ages 15 to 31 years, and several patients required mechanical ventilation.
Many reported vaping both e-cigarettes containing nicotine and THC oil, she said.
Health officials in that state interviewed eight of 15 patients hospitalized with vaping-related illness, and all eight .
Commercial Products Not Off the Hook
Griffith cautioned that commercial e-cigarette products haven't been completely ruled out.
"I don't think we can let the commercial nicotine e-cigarettes off the hook," she added, noting that early research suggests that certain flavorings in e-cigarettes may alter how the lungs process chemicals.
In an earlier press briefing, Brian King, PhD, of CDC office on smoking and health, noted that "e-cigarette aerosol is not harmless."
Gregory Conley, president of the vaping advocacy group American Vaping Association, told 鶹ý that he is confident the ongoing federal and state investigations will implicate black-market cannabis vaping products in the illnesses.
In an interview on CBS "This Morning" on August 28, Kevin Burns, CEO of the largest e-cigarette maker JUUL, said there's been no clear link between JUUL products and the reported cases. He added that he sees no reason to pull the e-cigarettes from the market, even temporarily, until more is known about the source of the sicknesses.
"If there was any indication that there was an adverse health condition related to our product, I think we would take very swift action associated with it," he told CBS, adding that the company is working closely with federal health officials in their investigations.
Vaping Disease Manifestations
John E. Parker, MD, of West Virginia University in Morgantown, was among the first clinicians in the country to warn of the potential for vaping-related lung injury after diagnosing lipoid pneumonia in a 31-year-old female e-cigarette user in acute respiratory distress.
The professor of pulmonary and critical care medicine told 鶹ý that he now believes there are at least three distinct manifestations of vaping-associated pulmonary injury: lipoid pneumonia, cryptogenic organizing pneumonia, and alveolar hemorrhage syndrome.
"I just saw a 19-year-old young man in the clinic yesterday with a 30-pound weight loss, two seizures, and evidence of some respiratory disease," he said.
Early in August, the FDA reported that it had received occurring between 2010 and 2017 and that it is investigating "to determine if there's a direct relationship" between the use of e-cigarettes and the incidents.
Aberegg said he also believes lipoid pneumonia is just one of several lung disorders that can be linked to vaping.
"The reason we jumped to that one, perhaps prematurely, is because we're finding abnormal immune cells in samples from patient's lungs that show evidence of lipid materials," he said, adding that this occurs with several different lung diseases.
"For me, the main importance of that finding is that it suggests the immune system is being revved up," he said.
Physicians Continue to Treat Cases
Utah resident Alexander Mitchell was gravely ill with lung failure earlier this summer when he was airlifted to the University of Utah hospital from his home 65 miles away, just days after waking up with severe nausea, chest pain, and trouble breathing.
His symptoms quickly progressed to acute respiratory distress syndrome (ARDS), and early testing at the presenting hospital ruled out the usual suspects.
Doctors there quickly suspected a vaping connection in Mitchell's case, and future testing indicated that he might be suffering from lipoid pneumonia.
Mitchell spent two weeks in the University of Utah hospital, including some days in the thoracic ICU on extracorporeal membrane oxygenation (ECMO) life support.
Aberegg, who was one of Mitchell's physicians, told 鶹ý that as of late August the hospital had treated more than half a dozen patients with probable vaping-related lung injury.
"After the first five, we have had another patient come in as a follow-up referral this week," Aberegg said, "and I was just alerted by another pulmonologist that there are two more in the hospital right now."