Lung injury associated with electronic cigarettes inhalation diagnosed by transbronchial lung biopsy

Abstract

A 46-year-old healthy man developed respiratory distress, night sweats, fever, and weight loss after using electronic cigarettes (e-cigs) for approximately 1 month. He presented to the hospital when the symptoms worsened 2 months after onset. The findings of bronchoalveolar lavage (BAL) fluid examination and the following transbronchial lung biopsy examination led to the diagnosis of acute alveolitis: intra-alveolar fibrosis accompanied with exudate containing abundant lipid-laden macrophages, eosinophils, and neutrophils. Eventually, e-cig-induced acute lung injury was diagnosed. The symptoms were rapidly alleviated upon e-cig use termination and methylprednisolone pulse therapy, and no subsequent recurrence was observed. There have been only a few reported cases of e-cig-induced lung injury. In e-cig users presenting with atypical pneumonia, close examination by BAL and biopsy should be performed to verify the presence or absence of lipid-laden macrophages.

Keywords: Acute lung injury; bronchoalveolar lavage; electronic cigarette; lipid‐laden macrophages; transbronchial lung biopsy.

Figure 1

(A) Radiography at admission revealed extensive ground‐glass opacity (GGO) in the bilateral upper lung fields, and GGO predominantly on the lateral segments of the lungs. (B) Computed tomography at the time of examination. Extensive GGO is seen in the upper lobes, accompanied with traction bronchiectasis. Non‐segmental GGO is seen in the lateral segments of lungs bilaterally, and a curvilinear shadow can be seen. (C) Chest radiography taken after 4 weeks of treatment. The opacity has almost disappeared.

Figure 2

(A) Neutral lipid‐laden macrophages in bronchoalveolar lavage fluid. (B) Intra‐alveolar organization and multinucleated giant cells. With eosinophilic exudate, cuboid type II epithelial growth can be seen. (C) Multinucleated giant cells can be seen in the alveolar ducts (arrow). (D) Macrophages containing blackish‐brown particles with eosinophilic and neutrophilic exudate can be seen in the alveolar space.