Chris Ratcliffe | Bloomberg | Getty Images
Dr. Lynn D'Andrea thought she was dealing with an infection when two teenage boys struggling to breathe arrived in intensive care at the Children's Hospital of Wisconsin over the Fourth of July week.
The teens had fevers and coughs and were fatigued, D'Andrea recalled. When she looked at the CT chest scans, their airways looked very sore, red and irritated. Some of the airways were even bleeding. The symptoms would have indicated an infection like pneumonia, but there should have been a lot of pus and there wasn't.
"It really looks like some sort of inhalation injury," said D'Andrea, a pediatric pulmonologist at the Wisconsin hospital.
Two other teens with similar symptoms arrived at the hospital the previous month. With four teens in the hospital — three of them in the ICU and all sick from a mysterious lung illness with no apparent cause — D'Andrea and her colleagues started to think it was something none of them had seen before.
Common theme
"It was like teenager, teenager, teenager and going. 'There's got to be a common theme here,'" said Dr. Mike Meyer, medical director of the pediatric intensive care unit, told colleagues at the time.
The only thing they all had in common was a history of vaping.
D'Andrea, Meyer and their colleagues at Children's would be among the first doctors in the nation to uncover and sound the alarm on the vaping lung illness, tentatively being called EVALI, short for e-cigarette, or vaping, product use associated lung injury. To date, the illness has taken the lives of 39 people and sickened at least 2,051 across 49 states, Washington, D.C., and the Virgin Islands. Alaska is the only state that has been spared.
Health officials still don't know exactly what's making people sick. The Centers for Disease Control and Prevention has dispatched more than 100 physicians and investigators to pinpoint the cause of the deadly outbreak, which it initially said resembled a rare form of pneumonia.
This August 2019 image provided by Intermountain Healthcare, shows an x-ray image of one of the first patients in Utah treated for vaping-related respiratory illness by Dr. Dixie Harris, an Intermountain Healthcare pulmonologist.
Intermountain Healthcare | AP
Early symptoms include coughing, shortness of breath, fatigue, chest pains, nausea, vomiting and diarrhea. State and federal health officials are painstakingly interviewing patients and their parents, gathering data on what the victims were vaping. They have covered about half the cases so far, according to CDC officials. FDA scientists are running tests on the actual vaping pens patients are using.
"Connecting the products and how they were used to specific patients is critically important to our investigation to determine to the extent possible the cause or the causes of these injuries," Mitch Zeller, the Food and Drug Administration's director of the Center for Tobacco Products, told reporters on an Oct. 25 conference call.
Public health officials are urging consumers to stop vaping, especially THC, the psychoactive ingredient in marijuana. A spike in teen use of e-cigarettes has prompted the Trump administration to draft new rules that would temporarily remove all flavored e-cigarettes from the market until the FDA can review their safety. Although doctors suspect THC as a possible problem, a portion of patients say they've only vaped nicotine.
The 'index' patient
It's unclear what role e-cigarettes have played in the illnesses, and research on vaping's impact on the lungs is scant.
The first case of EVALI appeared in April and rapidly increased beginning in July, even though consumers had been vaping for years. CDC officials have theorized that the rise of nicotine-filled e-cigarettes may have laid the groundwork for teens to start experimenting with riskier products, like THC, that led to the illness.
Some individuals who vape "are more frequently starting to experiment with other products," Dr. Anne Schuchat, the CDC's principal deputy director, told reporters last month. "That may be laying a fertile ground for the expanded use of risky products."
The Wisconsin doctors said their first patient, a male BMX biker labeled the "index" patient, was admitted on June 11. The teen had lost weight, had a fever and was having difficulty breathing, the doctors recalled.
"He was vaping and he was biking," D'Andrea said. "We really thought he had just probably inhaled some dust or dirt."
They conducted a standard chest x-ray and chest CT before taking him to the operating room for a bronchoscopy to rule out infection.
"Very quickly, it became evident that we didn't think that this was a typical community-acquired infection and that we needed more evaluation," Meyer said.
'This is not infectious'
It wasn't until the next three patients arrived that the doctors started putting it all together. Meyer said he can distinctly recall the exact moment D'Andrea said they may be dealing with an outbreak of some kind.
"She's like, 'This is not infectious,'" Meyer said. '"This does not look like a lung that has an infection. There clearly has to be something else. I just don't know what this is.'"
Prior to the lung illness outbreak, the doctors had already identified vaping as a common issue among teens. They had taken an extensive social history of the patients, including what the teens had been inhaling.
Among the 867 cases where the CDC has data on which substance patients were vaping, 86% said they used THC and 64% reported using nicotine. More than a third, 34%, said they exclusively used THC while 11% said they only vaped nicotine.
Sometime in mid-July, Dr. Michael Gutzeit, the hospital's chief medical officer, reached out to the Wisconsin Department of Health Services. On July 25, the doctors held their first press conference on EVALI, announcing that eight adolescents in the state had been hospitalized with severe pulmonary disease after vaping.
"We weren't sure what we were dealing with," Gutzeit said. "But we felt it was imperative to raise a warning to the public because of the significance of what we were finding and concern that this was a public health issue."
No one cause
Since then, Wisconsin officials have confirmed 82 probable cases in the state, with 14 other patients under investigation.
The Children's doctors said they worry the flu season could make it even worse, making it harder to detect and catch. And public health officials are still no closer to figuring out what exactly is making people sick.
"No one compound or ingredient has emerged as the cause of these illnesses to date; and it may be that there is more than one cause of this outbreak," the CDC says. "Many different substances and product sources are still under investigation."
Doctors initially said the illness resembled a rare form of pneumonia, caused by oil in the lungs, but a Mayo Clinic study cast doubt on that theory. Researchers who examined lung biopsies from 17 patients suspected of having the illness published astudy last month that said a mix of "toxic chemical fumes," not oils, may be to blame.
Officials aren't just looking at what's being vaped but also whether the heating process in e-cigarettes could be playing a role. They're analyzing what people vaped as well as the devices they used.
"I think that there will be multiple causes and potentially more than one root cause. I do think that the phenomenon we're seeing is going to have an explanation," Schuchat told reporters last month. "But it may not be tomorrow. It may take a few months to really understand the portion of illness that's due to some new risky practice in the preparation of these materials or other causes."
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