Morbidity and Mortality Weekly Report
Early Release / Vol. 68 

November 8, 2019

Evaluation of Bronchoalveolar Lavage Fluid from Patients in an Outbreak of
E-cigarette, or Vaping, Product Use–Associated Lung Injury — 10 States,
August–October 2019
Benjamin C. Blount, PhD1,*; Mateusz P. Karwowski, MD1,*; Maria Morel-Espinosa, PhD1; Jon Rees, PhD1; Connie Sosnoff, MA1; Elizabeth Cowan,
PhD1; Michael Gardner, MS1; Lanqing Wang, PhD1; Liza Valentin-Blasini, PhD1; Lalith Silva, PhD1; Víctor R. De Jesús, PhD1; Zsuzsanna Kuklenyik,
PhD1; Cliff Watson, PhD1; Tiffany Seyler, PhD1; Baoyun Xia, PhD1; David Chambers, PhD1; Peter Briss, MD2; Brian A. King, PhD3; Lisa Delaney,
MS4; Christopher M. Jones, PharmD, DrPH5; Grant T. Baldwin, PhD6; John R. Barr, PhD1; Jerry Thomas, MD1; James L. Pirkle, MD, PhD1

CDC, the Food and Drug Administration (FDA), state
and local health departments, and multiple public health
and clinical partners are investigating a national outbreak
of e-cigarette, or vaping, product use–associated lung injury
(EVALI). Based on data collected as of October 15, 2019, 86%
of 867 EVALI patients reported using tetrahydrocannabinol
(THC)-containing products in the 3 months preceding symptom onset (1). Analyses of THC-containing product samples
by FDA and state public health laboratories have identified
potentially harmful constituents in these products, such as vitamin E acetate, medium chain triglyceride oil (MCT oil), and
other lipids (2,3) (personal communication, D.T. Heitkemper,
FDA Forensic Chemistry Center, November 2019). Vitamin
E acetate, in particular, might be used as an additive in the
production of e-cigarette, or vaping, products; it also can be
used as a thickening agent in THC products (4). Inhalation of
vitamin E acetate might impair lung function (5–7).
Bronchoscopy and bronchoalveolar lavage† (BAL) can be
part of the clinical and diagnostic workup of EVALI patients.
The decision to perform this procedure is made by the clinical
team on a case-by-case basis (8). During August–October 2019,
BAL fluid specimens were collected by clinical teams caring
for hospitalized EVALI patients. Public health laboratories and
health departments from 10 states (California, Connecticut,
Hawaii, Illinois, Maryland, Michigan, Minnesota, Texas, Utah,
* These two authors contributed equally.
† Bronchoalveolar lavage, performed in the evaluation of lung disease, involves
instillation of sterile saline into a subsegment of the lung, followed by suction
and collection of the fluid for analysis.

and Wisconsin) coordinated the submission of residual BAL
fluid specimens from 29 patients to CDC.
To better characterize exposure among EVALI patients,
CDC developed and validated isotope dilution mass spectrometry methods to analyze specific toxicants of concern
and active compounds in case-associated BAL fluid.§ These
CDC analytic methods can identify vitamin E acetate, MCT
oil (medium chain triglycerides), plant oils (long chain triglycerides), petroleum distillates (including mineral oil), diluent
terpenes, cannabinoids, and nicotine in BAL fluid. The quality
of case-associated BAL specimens was assessed by measuring
dipalmitoylphosphatidylcholine (DPPC), the principal phospholipid in naturally-occurring lung surfactant: the presence of
acceptable levels of DPPC confirms that the lavage procedure
recovered adequate pulmonary epithelial fluid. When specimen volume was insufficient to perform all planned analyses,
analysis of vitamin E acetate and cannabinoids was prioritized.
Among the 27 BAL fluid specimens with sufficient volume for
testing, all had measurable levels of DPPC. Overall, 21 (72%)
patients with available specimens were male, and their median
age was 23 years (range = 16–67 years), which is consistent
with the sex and age patterns of EVALI patients reported to
CDC to date (1). Two of the patients died.
Vitamin E acetate was detected in all 29 patient BAL samples.
Among 23 patients for whom self-reported THC use information was available, 20 reported using THC-containing products. THC or its metabolites were detected in 23 of 28 patient
§ CDC has not yet published these validated isotope dilution mass spectrometry

methods.

U.S. Department of Health and Human Services
Centers for Disease Control and Prevention

 Early Release

BAL samples, including in those of three patients who said
they did not use THC products. Nicotine metabolites were
detected in 16 of 26 patient BAL specimens. Results for plant
oils, MCT oil, petroleum distillates, and diluent terpenes were
all below analyte-specific levels of detection (typically in the
low ng/mL range).
This is the first reported identification of a potential toxicant
of concern (vitamin E acetate) in biologic specimens obtained
from EVALI patients. These findings provide direct evidence of
vitamin E acetate at the primary site of injury among EVALI
patients and are consistent with FDA product testing and
media reports of state public health laboratory testing documenting vitamin E acetate in product samples used by EVALI
patients (2,3) (Personal communication, D.T. Heitkemper,
FDA Forensic Chemistry Center, November 2019). Other
diluents and additives of concern (e.g., plant oils, MCT oil,
petroleum distillates, and diluent terpenes) were notably not
detected in BAL fluid specimens from EVALI patients.
Although vitamin E acetate was detected in all specimens
in this analysis of a convenience sample of 29 EVALI caseassociated BAL specimens, additional studies are needed,
including comparison with BAL fluid specimens from healthy
volunteers and animal studies using controlled exposures to
establish whether a causal link exists between this exposure
and EVALI. Based on these data from 29 patients, it appears
that vitamin E acetate is associated with EVALI; however, it
is possible that more than one compound or ingredient could
be a cause of lung injury, and evidence is not yet sufficient to
rule out contribution of other toxicants to EVALI.
These findings reinforce CDC’s recommendation that persons should not use e-cigarette, or vaping, products containing
THC, especially those obtained from informal sources such as
friends or family, or those from the illicit market, where product
ingredients are unknown or can be highly variable (9). Until
the relationship of vitamin E acetate and lung health is better
characterized, it is important that vitamin E acetate not be
added to e-cigarette, or vaping, products. CDC will continue
to update guidance, as appropriate, as new data become available from this outbreak investigation.

Corresponding author: Benjamin C. Blount, bkb3@cdc.gov, 770-488-7894.
 1Division of Laboratory Sciences, National Center for Environmental Health,
CDC; 2Office of the Director, National Center for Chronic Disease Prevention
and Health Promotion, CDC; 3Office on Smoking and Health, National Center
for Chronic Disease Prevention and Health Promotion, CDC; 4Office of the
Director, National Institute for Occupational Safety and Health, CDC; 5Office

of Strategy and Innovation, National Center for Injury Prevention and Control,
CDC; 6Division of Overdose Prevention, National Center for Injury Prevention
and Control, CDC.

References
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mm6841e3
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MMWR  /  November 8, 2019  /  Vol. 68