Vitamin E acetate in Bronchoalveolar-Lavage Fluid associated with EVaLI

Introduction:
This text is a summary of a study on the causative agents of the current national outbreak of electronic-cigarette, or vaping, product use-associated lung injury (EVaLI) in the United States. The study utilized bronchoalveolar-lavage (BaL) fluid samples from 51 patients with EVaLI and 99 healthy participants to detect several priority toxicants, including vitamin E acetate, plant oils, medium-chain triglyceride oil, coconut oil, petroleum distillates, and diluent terpenes.

Key Points:

* The study found that vitamin E acetate was identified in BaL fluid obtained from 48 of 51 case patients (94%) but not in such fluid obtained from the healthy comparator group.
* No other priority toxicants were found in BaL fluid from the case patients or the comparator group, except for coconut oil and limonene, which were found in 1 patient each.
* among the case patients for whom laboratory or epidemiologic data were available, 47 of 50 (94%) had detectable tetrahydrocannabinol (ThC) or its metabolites in BaL fluid or had reported vaping ThC products in the 90 days before the onset of illness.
* Nicotine or its metabolites were detected in 30 of 47 of the case patients (64%).
* The study also notes that trade websites have reported the addition of various diluents, such as vitamin E acetate and medium-chain triglycerides, to ThC-containing products.
* The CDC obtained BaL fluid samples from 29 patients with EVaLI in 10 states and found the presence of vitamin E acetate in all 29 samples.
* This study extends that work by analyzing samples from 51 patients with EVaLI in 16 states along with samples obtained from 99 healthy participants in a smoking-related study.

Main Message:
The main message of the text is that vitamin E acetate is strongly associated with EVaLI in a convenience sample of 51 patients in 16 states across the United States. The absence of other priority toxicants in nearly all BaL fluid samples from case patients provides evidence against the role of any of these toxicants as a primary cause of EVaLI. The study suggests that vitamin E acetate may play a role in EVaLI and that results from studies in animals can provide information on whether exposure to vitamin E acetate alone can directly cause the lung injury seen in patients with EVaLI.

Blount, Benjamin C., Mateusz P. Karwowski, Peter G. Shields, Maria Morel-Espinosa, Liza Valentin-Blasini, Michael Gardner, Martha Braselton, et al. “Vitamin E acetate in Bronchoalveolar-Lavage Fluid associated with EVaLI.” New England Journal of Medicine 382, no. 8 (February 20, 2020): 697–705. https://doi.org/10.1056/NEJMoa1916433.