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Case Reports
. 2018 Dec 4:26:87-90.
doi: 10.1016/j.rmcr.2018.12.002. eCollection 2019.

Heat-not-burn cigarettes induce fulminant acute eosinophilic pneumonia requiring extracorporeal membrane oxygenation

Toshiyuki Aokage  1 , Kohei Tsukahara  2 , Yasushi Fukuda  3 , Fumiaki Tokioka  3 , Akihiko Taniguchi  4 , Hiromichi Naito  2 , Atsunori Nakao  2
Affiliations
Case Reports

Heat-not-burn cigarettes induce fulminant acute eosinophilic pneumonia requiring extracorporeal membrane oxygenation

Toshiyuki Aokage et al. Respir Med Case Rep. .

Abstract

Background: Although the cause of acute eosinophilic pneumonia (AEP) has not yet been fully clarified, cigarette smoking is reported to be a risk factor for developing AEP. The heat-not-burn cigarette (HNBC) was developed to reduce the adverse effects of smoke on the user's surroundings. However, the health risks associated with HNBCs have not yet been clarified. We report a successfully treated case of fatal AEP presumably induced by HNBC use.

Presentation of case: A 16-year-old man commenced HNBC smoking two weeks before admission and subsequently suffered from shortness of breath that gradually worsened. The patient was transferred to emergency department and immediately intubated because of respiratory failure. Computed tomography showed mosaic ground-glass shadows on the distal side of both lungs with a PaO2/FIO2 ratio of 76. The patient required veno-venous extracorporeal membrane oxygenation (ECMO) for severe respiratory failure. He was diagnosed with AEP by clinical course and detection of eosinophils in sputum; thus, methylprednisolone was administrated. The patient was weaned off ECMO four days after initiation and extubated the day after. He fully recovered without sequelae.

Conclusion: As far as we know, our patient is the first case of AEP induced by HNBC use successfully treated with ECMO. Emergency physicians must be aware that HNBCs can induce fatal AEP.

Keywords: AEP, acute eosinophilic pneumonia; Acute eosinophilic pneumonia; BAL, bronchoalveolar lavage; CT, computed tomography; Cigarettes; ECMO; ECMO, extracorporeal membrane oxygenation; Extracorporeal membrane oxygenation; FIO2, fraction of inspiratory oxygen; HNBC, heat-not-burn cigarette; Heat-not-burn cigarettes; IV, intravenous administration; PEEP, positive end-expiratory pressure; PSL, prednisolone; PaO2, partial pressure of arterial oxygen; Pplat, plateau pressure; SpO2, oxygen saturation of pulse oximetry; Tobacco; VV, veno-venous; mPSL, methylprednisolone.

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Figures

Fig. 1
Fig. 1
CT findings at emergency department. Non-contrast CT scan was performed using slice thickness 5 mm. The picture shows ground-grass findings spreading in both lungs. Such infiltrative shadows spread diffusely from the apex of each lung to above the diaphragm.
Fig. 2
Fig. 2
Sputum cytology on the first hospital day. The picture shows aggregation of eosinophils (arrows). The percentage of eosinophils increased slightly (14.7%). Many neutrophils were present (51.7%).
Fig. 3
Fig. 3
Clinical course. On the first day, the patient had little tidal volume. ECMO was needed for four days and the tidal volume (blue bar) increased gradually with administration of methylprednisolone. Interestingly, although blood tests showed no eosinophils on the first day, the elevation of eosinophils (orange line) reached 2980/μL on the seventh day.
See this image and copyright information in PMC

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