Pulmonary Function Testing in Patients With E-Cigarette, or Vaping, Product Use-Associated Lung Injury.

In 2019 there was an outbreak of respiratory illnesses amongst people who used E-cigarettes. This phenomenon was labeled 'EVALI' which stands for "Electronic cigarette (E-cigarette), or Vaping, Product Use-Associated Lung Injury" and is a life-threatening illness of the lungs associated with E-cigarette use. It is believed to be caused by certain chemicals in E-cigarette cartridges, such as vitamin E acetate, but the exact pathophysiological mechanism is yet to be elucidated. Since 2019, the CDC has recorded over 2800 cases in the United States with over 60 deaths. Though many people recover from EVALI, the long-term implications on pulmonary health are unknown. The purpose of this retrospective study was to demonstrate the pulmonary function test (PFT) findings in a group of patients who recovered from a diagnosis of EVALI. We reviewed the cases of 23 adult patients who presented to two major academic hospitals of the Northwell Health System with confirmed EVALI and followed up in our outpatient clinics with PFTs. Most patients had significantly reduced diffusion capacity (DLCO) demonstrating loss of functioning alveolar units. Given that average follow-up was over a month after discharge, this leads us to believe that EVALI can lead to persistent lung damage. However, further follow-up would be necessary to identify the full impact of E-cigarette use on the pulmonary function.

Pneumatosis Intestinalis in COVID-19: Case Series.

OBJECTIVE: To describe the clinical characteristics and outcomes of patients with coronavirus disease 2019 (COVID-19) who developed pneumatosis intestinalis (PI). METHODS: This case series was conducted in intensive care units at two large tertiary care centers within the Northwell Health System, located in New York State. Patients were included if they were identified as having confirmed COVID-19 as well as pneumatosis intestinalis from March 16, 2020 to July 31, 2020. Patient demographics, clinical characteristics, vasopressor use, anticoagulation use, opiate use, paralytic use, COVID-19 treatment regimen, serum lactate, arterial pH, serum bicarbonate, subsequent intervention, and outcomes during hospitalization were collected.  Results: A total of nine patients were identified. Average serum lactate was 4.33 mmol/L at time of diagnosis. Portal venous gas (56%) and bowel dilation (56%) were common radiographic findings. Subsequent morbidity (increased vasopressor requirements - 67%, acute kidney injury - 67%, increased oxygen requirements - 44%) and mortality (78%) were high. PI occurred despite a majority of patients being on anticoagulation (78%). Interleukin-6 (IL-6) inhibitors were commonly administered (56%) prior to development of PI. CONCLUSION: Pneumatosis intestinalis in COVID-19 is clinically significant, with high morbidity and mortality, and is also likely underdiagnosed.

Acute Respiratory Failure Associated With Vaping.

The use of e-cigarettes to deliver aerosolized nicotine has gained popularity in recent years. Numerous reports have cited the development of acute pulmonary disease linked to vaping nicotine as well as marijuana-based products. As cultural attitudes evolve and policies shift toward the legalization of marijuana, its use has become more prevalent. Given the increased prevalence of marijuana consumption and e-cigarette usage, better insight into its potential to cause lung toxicity is warranted. The clinical, radiographic, and histopathologic characteristics of lung injury associated with vaping, particularly with marijuana-based products, have yet to be well described in the literature. We present eight patients, most of whom were admitted recently to our institution with acute respiratory failure following vaping. The majority of patients were young, with a median age of 31.5 years (range, 24-62 years) and with no known underlying lung disease. This case series highlights common clinical findings as well as the varied radiographic and histopathologic features of acute respiratory failure associated with vaping predominantly marijuana-based products. As more cases of vaping-associated pulmonary injury unfold, data will be available to further characterize this emerging disease entity. Improved understanding of disease pathogenesis and its clinical course will help clinicians determine optimal management and follow-up strategies for this patient population.

Pathologic Findings in Bronchopulmonary Leukemic Infiltrates in Patients With Chronic Lymphocytic Leukemia.

INTRODUCTION: Chronic lymphocytic leukemia (CLL) is the most common lymphoproliferative disorder worldwide. Although thoracic complications are frequent in CLL, only limited data exists regarding these complications. Pleural, parenchymal, and airway disease may occur owing to CLL itself, treatment-related adverse events, typical or opportunistic infections, or from preexisting comorbidities. The etiology of parenchymal infiltrates is often attributed to pneumonia and can be difficult to properly identify without a diagnostic procedure. PATIENTS AND METHODS: We conducted a retrospective chart review of patients admitted from 2000 through 2016 with a diagnosis of CLL and abnormal radiography that underwent a bronchoscopy with biopsy, surgical lung biopsy, or transthoracic biopsies for nonresolving infiltrates after a course of antibiotics. We described the incidence of bronchopulmonary leukemic infiltrates (BPLI), describe other diagnosis achieved by the biopsy, and also describe the pathologic findings associated with BPLI in these patients. RESULTS: There were 111 procedures performed on 98 patients that yielded a diagnosis in 82 patients. In 16 patients, no histologic or pathologic diagnosis was identified after the biopsy. BPLI was diagnosed in 32 (39%) cases. In 27 (85%) of 32 cases, the biopsies returned with only BPLI owing to CLL (without inflammation), whereas 5 (15%) of 32 cases showed concomitant acute or chronic inflammation. CONCLUSION: Direct infiltration by leukemic cells may cause pulmonary symptoms and signs indistinguishable from infection. Biopsy is necessary to establish a definitive diagnosis, and physicians caring for these patients, including pathologists, should be aware of the clinicopathologic picture of BPLI to render an informative diagnosis.

Chylothorax in Patients with Chronic Lymphocytic Leukemia: A Case Series.

Chylothorax, which is defined as the presence of chyle in the pleural space, is often caused by malignancy. However, chylothorax as a result of underlying CLL is exceedingly rare in the literature. Chyle contains fat soluble vitamins and lymphocytes, meaning that its collection into the pleural space may further exacerbate the immunosupressed state of an individual with CLL. Here, we report three cases of patients with CLL who developed chylothorax, and their management. Chylothorax, although rare with CLL, should be considered in the differential diagnosis when patients with CLL present with pleural effusions, especially if recurrent. Discovery of a chylothorax may indicate the need for further treatment of CLL.

A 68-Year-Old Man With Dyspnea on Exertion and Cough.

A 68-year-old man with a history of chronic lymphocytic leukemia well controlled on ibrutinib, hypertension, obesity, and a remote history of smoking (10 pack-years) presented with increasing dyspnea on exertion and cough. He had previously finished two courses of oral antibiotics for his symptoms without significant improvement. On presentation, he had no fevers or sputum production.

Socioeconomic status and its relationship to chronic respiratory disease.

Socioeconomic status (SES) is defined as an individual's social or economic standing, and is a measure of an individual's or family's social or economic position or rank in a social group. It is a composite of several measures including income, education, occupation, location of residence or housing. Studies have found a lower SES has been linked to disproportionate access to health care in many diseases. There is emerging data in pulmonary diseases such as COPD, asthma, cystic fibrosis, pulmonary hypertension and other chronic respiratory conditions that allude to a similar observation noted in other chronic diseases. In the setting of COPD, SES has an inverse relationship with COPD prevalence, mortality, health utilization costs and HRQoL. Asthma and cystic fibrosis show an increased severity and hospitalizations in relationship to a lower SES. Similar observations were seen in sarcoidosis, PHTN and obstructive sleep apnea. There remains a limited data on non-CF bronchiectasis and interstitial lung diseases. Population SES may be gauged by various measures such as education, occupation, marital status but no value is more indicative than income. Currently guidelines and management algorithms do not factor the effect of SES in the disease process. Despite the great amount of data available, a standardized method must be created to include SES in the prognostic calculations and management of chronic pulmonary diseases.

Thoracic Complications in Chronic Lymphocytic Leukemia.

BACKGROUND: Chronic lymphocytic leukemia (CLL) is the most common lymphoproliferative disorder worldwide. Although thoracic complications are frequent in CLL, only limited data exist regarding the etiologies of these complications. MATERIALS AND METHODS: A retrospective chart review was performed on all patients admitted to a tertiary care, CLL referral center, with CLL and a respiratory complaint from 2001 through 2013, to categorize pulmonary complaints and diagnoses. RESULTS: There were 277 patients with CLL admitted on 409 occasions with respiratory complaints. The median age was 73 years, with a male to female ratio of 2:1. The majority of patients had a high-risk Rai classification and had received prior treatment. Common presenting symptoms included dyspnea, cough, and sputum production. The most common diagnoses were pneumonia (62.8%), with an identified organism in 44.7%, pleural effusions (31.8%), lung cancer (6.9%), and leukemic infiltrates (5.9%). Invasive procedures were performed 138 times: 70 bronchoscopies, 24 surgical lung biopsies, 10 computed tomography-guided lung biopsies, and 34 thoracenteses. In-hospital mortality was 24.9%. In a multivariable analysis, an elevated blood urea nitrogen level and creatinine, thrombocytopenia, and a presenting symptom of dyspnea correlated significantly with in-hospital mortality. CONCLUSION: Thoracic manifestations in CLL are common among hospitalized patients. Although infectious pneumonia remains most common, unusual or opportunistic infections may be increasing, and direct lung damage owing to CLL itself or to newer biologic agents are being diagnosed with lung tissue sampling. Recognition of these complications will allow earlier diagnosis, which may change management including removal of offending biologic agents or augmentation of treatment for CLL when infiltrative leukemic cells are present.