May 27, 2020

Uncovering the Uncommon: Commonalities Between COVID-19 and EVALI

May 27, 2020
EVALI (E-cigarette or Vaping product use-Associated Lung Injury) signals sweeping indicators that commonly coincide with other lung diseases, such as COVID-19.

E-cigarette or vaping product use-associated lung injury, better known as, EVALI, was first strongly recognized by the Center for Disease Control and Prevention (CDC) in August 2019, after a surge of Vaping Associated Pulmonary Illness, or VAPI. The diagnostic criteria for EVALI, provided by the CDC, encompass the existence of pulmonary infiltrate, which occurs when a condensed substance, such as pus or blood, remains within the lung. Non-resolving and slow resolving cases of pneumonia are the most prevalent classifications of pulmonary infiltrate. Radiologic scans project that ironically, EVALI signals sweeping indicators that commonly coincide with other lung diseases, such as COVID-19. Both conditions cause pneumonia and lung injury, which may explain the alignment of imagery in these ailments. 

As it turns out, according to a recent webinar moderated by Dr, Patrick Colletti, MD, (Keck School of Medicine of USC), COVID-19, the notorious, yet novel strain of the Coronavirus and EVALI, appear to have an array of similarities via observation of computed tomography imagery, better known as a CT scan. However, the diagnostic methodology that helps translate such complex respiratory conditions is also reflecting differing contrasts between COVID-19 and EVALI.

While EVALI is not a contagious disease, relative to COVID-19, health officials across the United States have documented dire injury cases of EVALI lung disease, some resulting in mortality, in relation to both conditions– in otherwise, seemingly healthy individuals. 

Indications of Illness: COVID-19 and EVALI Symptoms

Let’s discuss the lesser-known commonalities between these two newly discovered conditions. 

Photo courtesy via screenshot of the AARS webinar moderated by Dr. Patrick Colletti, MD

“EVALI and COVID-19 cause lung injury, and both cause, as a result, organizing pneumonia,” stated Dr. Travis Henry, professor of cardiothoracic imaging at the University of California, San Francisco, during the AARS webinar. Individuals who vape may present symptoms such as fever or coughing, also parallel symptoms associated with COVID-19. With such distinct similarities between COVID-19 and EVALI, the question at hand when deciphering imagery in a patient who also vapes, ultimately boils down to determining if this individual suffers from EVALI or, potentially, COVID-19. 

“So how can we determine which patient with lung injury has COVID-19 and which one has EVALI, or influenza A, or antisynthetase syndrome, etcetera? You need to know what the clinical context is. We have no idea based on CT (scan) alone.”

-Dr. Henry, USC

Thus far, research has projected contrasting discoveries in regards to the utilization of CT scan to potentially diagnose COVID-19, with studies reporting sensitivity for the test spanning from roughly 50% to 98%, depending on specific guidelines followed. Although he noted in the webinar specific patterns that can occur consistently in cases of both EVALI and COVID-19, that could help differentiate between the two lung diseases. 

For EVALI, the most prevalent radiological features are organizing pneumonia, alveolar damage, alveolar hemorrhage, and centrilobular nodularity — typically characterized by scant traces of ground-glass that slowly expand, accumulating symmetrically and fused over periods of time. While the prevailing CT indicators of COVID-19 may also include what appears to be the presence of a glassy opacity, along with indications of organized pneumonia however, those findings maintain what appears to be fringe distribution.

Some cases documented prevalent EVALI symptoms as soon as days after exposure, whereas, other individuals took several weeks to notice conditions associated with the lung-related illness, yet another similar trend found with COVID-19. 

The EVALI Results Are In

Laboratory data has shown that vitamin E acetate (an additive in various THC-containing e-cigarette, and vaping products) is strongly linked to the EVALI outbreak. Stipulations of the bans have been loosened considerably, but are still being upheld in a variety of states. 

The New England Journal of Medicine published a newly released study that according to the CDC: “…analyzed samples from 51 EVALI cases from 16 states and a comparison group of samples from 99 comparison individuals without EVALI for vitamin E acetate, plant oils, medium-chain triglyceride (MCT) oil, coconut oil, petroleum distillates, and diluent terpenes.”

The conclusion was that Vitamin E Acetate was found to be closely associated with EVALI, via the samples provided from 51 patients in 16 states spanning across the United States.

According to the CDC, “As of February 18, 2020, a total of 2,807 hospitalized EVALI cases have been reported to CDC from all 50 states, the District of Columbia, and two U.S. territories (Puerto Rico and U.S. Virgin Islands). Sixty-eight deaths have been confirmed in 29 states and the District of Columbia (as of February 18, 2020).” This pales in comparison to the novel coronavirus statistics

The CDC has not updated statistics for EVALI-related illness since February, 2020, just shy of one month after the first documented case of COVID-19 in the U.S. While the number of new emerging EVALI cases continues to decrease, and emergency room visits for COVID-19 increase — with chronic lung conditions among the high-risk category, many cannabis consumers are still left with unanswered questions. 

Smoke and Mirrors

(Darion Cole, Coordinating Outreach Representative at ZenLeaf dispensary, Canton, Ohio. She previously worked in a pharmacy for six years in West Virginia, when she made the choice to relocate, to Ohio.)

“If cannabis isn’t for you, that is fine, but it is not fair to keep it hostage to those who are desperately in need of it.”

– Darion Cole

Amidst the ongoing viral COVID-19 pandemic, to the shock of many, the cannabis industry has remained open to the public as an essential business operation. Rightfully so, as wide-spread cannabis utilization is critically imperative in such unprecedented times. 

However, many are taking extra precautions to combat the deadly virus, once again raising questions about personalized methods of cannabis consumption, such as smoking or vaping — once again a common denominator with EVALI.

In fact, in the eye of the uproar of concern for public safety, both tobacco and THC infused products were both temporarily banned from sales in the United States. The temporary ban went into full effect, specifically focused on flavored marijuana vaping products on October 11, 2019, and flavored tobacco vaping products soon followed suit on November 1, 2019. At the time EVALI was first discovered in 2019, many were unclear what the direct causation of this epidemic was, as many individuals interchangeably vaped both cannabis and tobacco products for long durations of time, without any EVALI/VAPI-related illness. 

That specific scenario begged the question, could interchangeably using e-cigarettes (for both nicotine and MMJ) complicate long-term risk? Darion Cole, Outreach Coordinator for ZenLeaf gave her perspective:

 “I think that could be an issue when trying to get down to the underlying problem. With vaporization, you have to get it to liquid form, in most cases, to get that aerosol like effect. By doing so, you are starting to add liquids and flavor compounds that could possibly irritate the delicate tissues and air sacs in the lungs.”

Should this be a reason to reconsider consumption methodology? 

“Vaporizing flower-bud doesn’t pose the (same) risks that would come with certain liquids. Vaping dry bud has proven more (health) benefits than smoking it. The biggest culprit when relating deaths to vaping, as we know, is the Vitamin E acetate that people were adding into the THC as a filler or a dilution to the THC. Topically Vitamin E acetate shows no threat to humans, however, when ingested (it) is a different story.

However, it appears that vaping cannabis, as opposed to smoking, may expose you to fewer of the toxic compounds that you get when you burn the plant. Evidence collected found that cannabis users with breathing problems were able to recover some of their lung function after making the switch to vaping. 

In addition, discoveries of certain plant-based terpenes have been found to possess potent antiviral properties used to fight against Severe Acute Respiratory Syndrome. In total, 221 compounds were evaluated for the potential efficiency to combat SARS-CoV. Cannabinoids have been found to be powerful antimicrobials, helping certain types of viral infections by working to eliminate many types of bacteria and fungus. Cannabinoids can even successfully combat superbugs like MRSA and various other fungal infections, such as Candida. This ideology goes deep into the marrow of history, hundreds if not thousands of years, now supported by modern science and medicine. Which raises the question, could cannabis terpenes be used as useful agents in combating against other viral conditions, such as COVID-19? Only time will tell. 

(Dr. Bridget Williams is the owner of Green Harvest Health, a medical cannabis clinic located in Pickerington, OH. Green Harvest Health is the only medical cannabis clinic in Ohio with life and wellness coaching incorporated into the practice. Dr. Williams brings nearly 20 years of experience in family and occupational medicine from Cleveland Clinic and training in life and cannabis coaching to her practice. Dr. Williams provides valuable talks on medical cannabis, CBD, and balanced wellness across Ohio as well as teaching at the Cleveland School of Cannabis.) 

“Vaping is a powerful way to obtain the benefits of medicinal cannabis quickly within 30 sec to 5 minutes.  This can be helpful for patients suffering from panic attacks, debilitating pain, seizures, migraines, and much more.”

-Dr. Williams

In your perspective, is vaping considered to be safer than smoking cannabis? 

“Is it safer than smoking [cannabis]? Yes. However, whenever one inhales a substance into their lungs other than clean air there are potential related risks. Concerns related to Vaping Associated Pulmonary Injury (VAPI) have been determined to be caused by vitamin E acetate, an ingredient introduced in black market products. Therefore vaping can be concerned safer with dispensary products that are third party tested, versus black market items in which contents are unknown. It is now known that the substance was introduced via (the) black market [cannabis] products.”

Advice for patients?

“If patients choose to vape, consider that the best and safest options available are dispensary products that have been tested by third-party laboratories. They can assure the safety of the product.”

It’s important to know the similarities between EVALI and COVID-19, especially if you opt for consumption via inhalation, versus alternative methods such as edibles, etc. Professionals all across the board seem to agree that vaping cannabis is overall a safer consumption method than smoke inhalation, which is imperative to consider in these dire times. Echoing the sentiment that knowing your source is crucial, only purchase products from reputable, trusted facilities. Establishments that not only carry quality products, but ones that equip a knowledgeable staff, that will ultimately help to guide you in the right direction to keep your overall best interests at heart. 


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