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BACKGROUND: The use of e-cigarettes is on the rise around the world. Many case reports of acute lung injury due to e-cigarette use have been published in recent months in the USA, but no comparable cases have emerged in Germany up to the present report. The use of e-cigarettes has risen very rapidly in the USA in recent years, simultaneously with the legalization of marijuana sale in many American states. Most of the cases described there involved the use, not only of nicotine, but of tetrahydrocannabinol (THC, the psychoactive ingredient in marijuana) as well, though some of the patients had indeed not used additives (e.g. THC). METHODS: We report three cases in Germany of acute pulmonary illness that we consider to have been caused by the use of e-cigarettes. RESULTS: All three patients were hospitalized for acute shortness of breath. Two displayed partial respiratory insufficiency and bilateral pulmonary infiltrates. All three stated that they had used ordinary, commercially available e-cigarettes every day for at least the past three months. In the first patient, a 48-year-old man, the complete blood count and bronchial lavage findings indicated eosinophilic inflammation. The second patient, a 22-year-old man, developed multiple episodes of hemoptysis, with computed tomography (CT) showing diffuse alveolar bleeding; his complete blood count also revealed eosinophilic inflammation. The third patient, a 34-year-old man, displayed acute ground-glass lung opacities as well as fibrosing changes on CT corresponding to pulmonary sarcoidosis. All three recovered on high-dose systemic corticosteroid treatment and were discharged from the hospital in 2 to 12 days. CONCLUSION: In the first two cases, acute pulmonary injury was very likely due to e-cigarette consumption, as all other possible causes were ruled out. A possible link to e-cigarette use was present in the third case. We thus describe the first three suspected cases of acute lung disease due to e-cigarette use in Germany. These patients do not share any common, typical clinical picture; rather, their symptoms represent different components of the wide spectrum of interstitial lung disease. A uniform national registry should be established to improve our understanding of the adverse effects of e-cigarettes and the resulting acute and chronic changes in the lungs.

Summary Background To evaluate the utility of home spirometry (HS) versus office spirometry (OS) in assessing treatment response to azithromycin in bronchiolitis obliterans syndrome (BOS). Methods 239 Lung transplant recipients were retrospectively studied. ΔFEV 1 ± 10% from FEV 1 at azithromycin initiation for ≥7 consecutive days in HS or ≥2 measures in OS were taken as cut-off for response or progression. Results Based upon HS, 161/239 (67%) patients were progressive despite macrolide, 19 of who exhibited transient improvement in FEV 1 (11%). Time to progression was 29 (13–96) days earlier with HS than in OS. Forty-six (19%) recipients responded in HS after median 81 (22–343) days, whilst 22% remained stable. Concordance in azithromycin treatment response between OS and HS was observed in 210 of 239 patients (88%). Response or stabilization conferred significant improvement in survival ( p = 0.005). Transient azithromycin responders demonstrated improved survival when compared to azithromycin refractory patients ( p = 0.034). Conclusions HS identified azithromycin refractory patients significantly earlier than OS, possibly facilitating aggressive treatment escalation that may improve long-term outcome. Treatment response to azithromycin should be assessed 4 weeks after initiation. Responders demonstrated best survival, with even transient response conferring benefit. Macrolide-refractory BOS carried the worst prognosis.