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Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin — Preliminary Report

posted 06/09/2019

publication DOI: 10.1056/NEJMoa1911614

Jennifer E. Layden, M.D., Ph.D., Isaac Ghinai, M.B., B.S., Ian Pray, Ph.D., Anne Kimball, M.D., Mark Layer, M.D., Mark Tenforde, M.D., Ph.D., Livia Navon, M.S.,
Brooke Hoots, Ph.D., Phillip P. Salvatore, Ph.D., Megan Elderbrook, M.P.H., Thomas Haupt, M.S., Jeffrey Kanne, M.D., Megan T. Patel, M.P.H., Lori Saathoff-Huber, M.P.H.,
Brian A. King, Ph.D., M.P.H., Josh G. Schier, M.D., Christina A. Mikosz, M.D., M.P.H.,and Jonathan Meiman, M.D. et al.



E-cigarettes are battery-operated devices that heat a liquid and deliver an aerosolized product to the user. Pulmonary illnesses related to e-cigarette use have been reported, but no large series has been described. In July 2019, the Wisconsin Department of Health Services and the Illinois Department of Public Health received reports of pulmonary disease associated with the use of e-cigarettes (also called vaping) and launched a coordinated public health investigation.


We defined case patients as persons who reported use of e-cigarette devices and related products in the 90 days before symptom onset and had pulmonary infiltrates on imaging and whose illnesses were not attributed to other causes. Medical record abstraction and case patient interviews were conducted with the use of standardized tools.


There were 53 case patients, 83% of whom were male; the median age of the patients was 19 years. The majority of patients presented with respiratory symptoms (98%), gastrointestinal symptoms (81%), and constitutional symptoms (100%). All case patients had bilateral infiltrates on chest imaging (which was part of the case definition). A total of 94% of the patients were hospitalized, 32% underwent intubation and mechanical ventilation, and one death was reported. A total of 84% of the patients reported having used tetrahydrocannabinol products in e-cigarette devices, although a wide variety of products and devices was reported. Syndromic surveillance data from Illinois showed that the mean monthly rate of visits related to severe respiratory illness in June through August of 2019 was twice the rate that was observed in the same months in 2018.


Case patients presented with similar clinical characteristics. Although the features of e-cigarette use that were responsible for injury have not been identified, this cluster of illnesses represents an emerging clinical syndrome or syndromes. Additional work is needed to characterize the pathophysiology and to identify the definitive causes.

Disclosure forms provided by the authors are available with the full text of this article at

This article was published on September 6, 2019, at

We thank the staff of the Wisconsin Department of Health Services and Illinois Department of Public Health and numerous local health departments and hospitals who played a critical role in this investigation and collected the information provided in this article; members of the investigative team, including Carrie Tomasallo and Barbara Grajewski of the Wisconsin Department of Health Services; Connie Austin, Judy Kauerauf, and Matt Charles of the Illinois Department of Public Health; and Michael Gutzeit, Lynn D’Andrea, and Lori Loof of the Children’s Hospital of Wisconsin, for their recognition of the cluster and assistance with the public health investigation; Grant T. Baldwin, Debra Houry, Dana Meaney-Delman, and Ileana Arias of the Centers for Disease Control and Prevention (CDC); and the CDC 2019 Lung Injury Response team.

Author Affiliations

From the Illinois Department of Public Health (J.E.L., I.G., L.N., M.T.P., L.S.-H.), Springfield; the Epidemic Intelligence Service, Center for Surveillance, Epidemiology, and Laboratory Services (I.G., I.P., A.K., M.T., P.P.S.), National Center for Environmental Health (M.L.), the Division of State and Local Readiness, Center for Preparedness and Response (L.N.), the Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control (B.H., J.G.S., C.A.M.), and the Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion (B.A.K.), Centers for Disease Control and Prevention, and Emory University School of Medicine (M.L.) — all in Atlanta; the Wisconsin Department of Health Services (I.P., M.E., J.M.), the Wisconsin Division of Public Health, Bureau of Communicable Disease (T.H.), and the Department of Radiology, University of Wisconsin School of Medicine and Public Health (J.K.) — all in Madison.

Address reprint requests to Dr. Layden at the Illinois Department of Public Health, 69 W. Washington St., Chicago, IL 60602, or at

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