As the number of vaping-related illnesses continues to climb in the U.S., pathologists who diagnose lung injuries as part of a larger healthcare team, say it’s not easy to see the signs of vaping under a microscope.
But that may be changing as scientists identify the visual cues common in patient specimens, whether or not they are forthcoming about their vaping habits. A new study published in the New England Journal of Medicine (NEJM) and reported in The New York Times compared vaping related lung damage to the same type of damage caused by chemical burns.
Moises Velez, M.D. is the director of the Thoracic Pathology subspecialty service at the University of Rochester Medical Center. He and fellow cytopathologists, Tanupriya Agrawal, M.D., Ph.D. and Ellen Giampoli, M.D. shared more about the ways in which vaping is showing up in everyday diagnoses, and how recognizing the signs can get patients help quicker.
What exactly does a thoracic pathologist do, and what do they look for?
Normal lung cells as seen under a microscope after staining, at 20x magnification.
Visible inflammation in lung cells of a patient known to have vaped (magnified at 40x).
Normal lung fluid magnified 40x.
Lung fluid (magnified 60x) of a patient with a history of vaping. The lipid or oil in the cells stain red with Oil Red O. This is presumably caused by vaping or inhaling an aerosolized oily substance.
Velez: A thoracic pathologist is a specialized doctor that diagnoses diseases of the thorax, or chest cavity, by looking at tissue or fluid specimens under a microscope. Hundreds of disease which fall into this category.
Have you ever encountered a case in which a patient had lung damage due to vaping?
Agrawal: To date, I have received four bronchoalveolar fluid specimens (BAL) that came from patients with a history of vaping. Each patient presented with signs of respiratory failure.
In recent months, I had a teenage patient who was admitted to the ED with respiratory failure. They had a history of marijuana use and couldn’t remember what they inhaled the day before, but had vaped a few months before.
What is known from the literature is that vaping can present acutely and up to 90 days. So if someone has vaped in the last 90 days, it can present later. Because of the history for vaping, the patient was treated with steroids and antibiotics and later discharged.
Why is it difficult to know what damage is caused by vaping?
Velez: Recent literature in the NEJM reported patterns of lung injury such as diffuse alveolar damage, organizing pneumonia, granulomatous pneumonitis and foamy macrophages in patients with a history of vaping. We know these patterns of lung injuries described are not specific to any disease process.
For example, they can also be seen in an infection, sepsis, drug toxicity, toxic inhalation, and collagen vascular disease to name a few. If the history of vaping is known, Oil Red O may be performed to identify lipid in macrophages. Knowing the clinical history is the key make the association of vaping and lung injury.
Aren’t there other methods, like CT images, to detect a lung injury that could be vaping-related?
Velez: Clinicians suspect lung injury if someone has been inhaling something recently (such as e-cigarette vapor) and they develop shortness of breath and come to the ED. Then they may undergo a chest CT. The radiologic findings are not specific and show patterns that can correlate with eosinophilic pneumonia, diffuse alveolar damage organizing pneumonia and lipoid pneumonia. The history of inhalation coupled with the radiologic and histologic evidence of the lung injury, means you can suspect this was due to vaping.
In other words, a pathologist can probably tell a person is sick because of vaping, based on what they see under the microscope, but unless you know from the patient’s doctor that they vape, you can’t link the two?
Agrawal: Correct. If we are not provided with the patient’s history, it’s just an acute lung injury for us. Maybe the patient has an infection, but unless a history or clinical report is provided or there is some clinical suspicion, we as pathologists cannot make a determination.
Do you think patients don’t want to disclose that they’ve vaped for fear of stigma, or that they’ll be punished for doing something illegal (especially if they vape an illegal substance like marijuana)?
Velez: It’s uncertain if vaping carries any stigma at all, but it’s possible that youth may conceal their habits. There are over 2,000 flavors of vaping cartridges, so it’s enticing. The nicotine vaping cartridges also contain as much nicotine as a pack of cigarettes. None of this is FDA-regulated.
Agrawal: With teenagers especially, they want to experiment with vaping and mixing edible oils so nobody knows exactly what they’re inhaling, how it’s being transformed as it goes into the lungs. There is no research out yet on this.
Some see vaping as an epidemic. What’s one practical way clinicians can help fight it?
Giampoli: Our physicians and ER docs on the front lines need to get nosy and ask patients if they vape. At the moment there’s nothing specific for us to identify it with until we see more cases and can identify patterns in what we’re looking for.
Our whole job is finding patterns with the information we have. We will be able to recognize these cases faster, pick up these connections quicker, and hopefully be able to help our clinicians help these patients much more quickly.
Neil Blumberg, M.D., professor of Pathology and Laboratory Medicine and director of Blood Bank/Transfusion Medicine at the University of Rochester Medical Center, is being inducted into the National Blood Foundation Hall of Fame on Oct. 19, 2019.
For more than 30 years, Blumberg and a team of collaborators have been investigating how to make blood transfusions safer for the millions of hospitalized patients who receive them every day. He’s been an ardent local, regional, and national advocate for fewer transfusions, despite push-back from many in the medical field.
Some of his earliest work, which established Blumberg as a leader, showed poorer outcomes for cancer patients who received donor blood. These study results changed clinical practice at URMC and increased the survival odds for young leukemia patients. Later, Blumberg showed that filtering the foreign white blood cells from donor blood when transfusions are necessary resulted in fewer cardiopulmonary complications for patients.
And in 2014, Blumberg and co-authors published a groundbreaking JAMA analysis showing that doing fewer blood transfusions reduces infection rates by nearly 20 percent. The study was the first to show conclusively — by analyzing 18 randomized clinical trials involving 8,700 patients — that reducing the number of transfusions not only saved lives but can decrease health care costs significantly.
“My advice to young physicians, medical technologists, scientists and nurses who want to do research is to find problems you think are important and are passionate about,” Blumberg said, in a recent article in the American Association of Blood Banks newsletter that honored his Hall of Fame recognition.
“Don’t allow failure or disapproval of your results by others discourage you too much,” he said. “Consider feedback, but if you find results contrary to the conventional wisdom, read about Semmelweis, whose instructing physicians to wash their hands prior to delivering babies was met with contempt. Read about Bernard Fisher, the surgeon whose work demonstrating that the Halstead radical mastectomy was ineffective and only created suffering was met with a mixture of disbelief and anger. It is always first and foremost the work and its benefit to patients that should be your focus.”
None of his research would have been possible, he said, without help from numerous close associates, including his spouse, Joanna M. Heal, MBBS, retired physician at the American Red Cross and UR Medicine’s Hematology/Oncology unit; the technical staff and attending physicians in the Transfusion Medicine service at Strong Memorial Hospital; the nursing staff at Wilmot Cancer Institute and Strong Memorial; and several faculty from Pediatric Surgery, Pulmonary and Critical Care Medicine, and from Wilmot.
The AABB will feature Blumberg as a keynote speaker at its annual meeting in San Antonio, Texas, where the Hall of Fame induction takes place.
- Leslie Orr
This month marks five years since Strong West officially opened in Brockport, and the clinical lab is an important part of the small but mighty healthcare team serving patients on the west side.
Sue Baker is supervisor of the Strong West lab, which runs an average of 6,800 lab tests each month – which is more than six times the number it processed when it first opened.
She oversees a team of two other fulltime medical technologists (Elizabeth Chartraw and Becky Phelps) who operate 24/7 with assistance from three med techs from the Strong Memorial Hospital lab who help cover shifts. The lab also currently has open positions.
Working at Strong West means the lab is part of a highly collaborative healthcare team – where you get to know the names and faces of the nurses and attending physicians in the Emergency Department and other service lines.
“It’s a different look at medicine in a lot of ways,” said Baker. “It’s more collaborative and it lets a lot of camaraderie go forward so we’re not just ‘the lab’ anymore. It’s ‘Sue that works in the lab,’ and I think that’s a nice kind of difference.”
The lab team is responsible for intake, testing, and reporting results of patient specimens. While their test volume isn’t nearly as big as larger labs at Strong Memorial Hospital or Bailey Road, it means the team must cover certain tasks themselves.
For example, there isn’t a separate team to handle specimen receiving, materials management staff, or maintenance and quality control for the lab’s 12 analyzers.
“We do all our receiving and spinning of specimens,” Baker said. “We unpack all our own boxes and do inventory. There’s more to what we do than just bench work.”
Everyone who works at Strong West serves a unique purpose of providing care for patients who can access services close to home without having to drive into Rochester – and the staff are reminded of this on a daily basis.
You can walk into a store in the village of Brockport wearing your University ID badge and people will say thank you for working in our community, Baker says. “There’s a nice community feel here, not only in the community but in the building itself.”
In photos: The Strong West lab’s three fulltime med techs include (from left) Becky Phelps, Sue Baker (supervisor), and Elizabeth Chartraw.
Approximately 500 staff who worked at Strong Memorial Hospital and other UR Medicine Labs sites will relocate to the central laboratory at 211 Bailey Road, in Henrietta. Clinical lab testing officially went live on June 24. All inpatient, emergency and on-campus clinics will remain at Strong Memorial Hospital.
Read the full article in the URMC Newsroom for more information.
View photos from this event.
Pathology Research Day at the University of Rochester Medical Center was held on Monday, June 10, 2019.
The day included 51 poster presentations in addition to 13 oral presentations given by Pathology & Laboratory Medicine residents and fellows and graduate students in the Cell Biology of Disease Ph.D. Program.
This year’s keynote speaker was Thomas Wynn, Ph.D., Vice President of the Discovery Inflammation and Immunology Group for Pfizer Corp., in Cambridge, Mass.
View Event Photos
Graduate Program Awards
- Outstanding Academic Excellence by a First Year Student – Cooper Sailer, MS
- Outstanding Program Contribution – Katherine Best, MS, and Brianna Shares, MS
- Robert Mooney Thesis Award – Richard Bell, Ph.D.
Best Oral Presentation
Poster Presentation Travel Awards
- Madison Doolittle, MS
- Felicia Gilels, MS
- John Bachman, MS
- Jerry Saunders III, MS
Oral Presentation Awards
- Mushal Noor, M.B.B.S.
- Phoenix Bell, M.D.
- Anna Israel, M.D.