Miasma
Want to know the common way people are exposed to the chemical causing lung damage in microwave popcorn workers? What vitamin might be toxic for your lungs and how you can inhale heavy metals without welding? Listen to find out!
This is the Pick Your Poison podcast. I’m your host Dr. JP and I’m here to share my passion for poisons in this interactive show. Will our patients survive this podcast? It’s up to you and the choices you make. Our episode today is called Miasma.
Want to know the common way people are exposed to the chemical causing lung damage in microwave popcorn workers? What vitamin might be toxic for your lungs and how you can inhale heavy metals without welding? Listen to find out!
A 16-year-old boy presents to the emergency department complaining of shortness of breath. He's had a cough and fever for a week. He’s otherwise healthy with no history of asthma or lung disease. Mom says she took him to an urgent care a few days ago where he was diagnosed with a viral infection. The symptoms have worsened, now he has shortness of breath and trouble breathing.
The triage vital signs are as follows: temperature of 103.2 F or 39.5 C, heart rate is 129 beats per minute, respiratory rate 40 breaths per minute, and oxygen saturation is 93% on room air. The chart says no medicines, no tobacco, alcohol and drugs. So, he has a fever, a fast heart rate and breathing, an adequate oxygen saturation, but low for an otherwise healthy child.
On physical exam, he has an increased work of breathing with retractions, meaning you can see his clavicles and ribs as he breathes hard, trying to suck in more air. His heart is fast, but sounds normal. His lung sounds are coarse and rhonchus, but there’s no wheezing. He doesn’t have any lower extremity swelling and the rest of his exam is unremarkable.
What tests do you want? This is an easy question. The main tests we need are a chest x-ray and a Covid swab. You might do some labs, including a white blood cell count and a lactate to evaluate for sepsis. Mom says the Covid swab was negative at the urgent care, so we can rule that out.
This seems like a pretty straightforward case. There’s a saying in medicine, often told to medical students and residents, ‘When you hear hoofbeats think horses not zebras’, meaning common things are common. I love zebras, rare and unusual diagnoses, that’s why I’m a toxicologist, but the evidence in this case points to a basic respiratory infection like a virus or pneumonia. The chest x-ray should point us in the right direction.
You enter the orders to get diagnostic testing underway. Question #1. What's the next best step?
A. ask Mom to step out of room so you can speak to the patient alone
B. a breathing treatment
C. supplemental oxygen
D. antibiotics
Answer: A. ask Mom to leave the room. Breathing treatments help with asthma or bronchitis, the patient doesn’t have any wheezing. Antibiotics of course help with pneumonia, we need the chest x-ray to see if it shows this diagnosis. His oxygen saturation is good, so extra oxygen won’t help. We need to talk to this teenager without Mom, in the hope- let me emphasize hope- of getting the truth about sensitive topics like sex, drugs and alcohol.
In medical school you learn this is an important part of adolescent medical care. The good news is most parents these days expect it. I’ll share with you that I learned to do this the hard way with adult patients too. When I was an intern, an older man complained of chest pain. It was unstable angina, cardiac chest pain, so I wanted to give nitroglycerin to relieve the pain. He was taking Viagra. You may know nitro is contraindicated with recent Viagra use, due to a drug interaction that can result in life-threatening low blood pressure. With his wife sitting at the bedside, he said he hadn't taken Viagra for about a week, a safe distance in the past, so I ordered the nitro. Shortly thereafter, I returned to check on him. He was alone, his wife had gone to the cafeteria. He then disclosed he’d taken Viagra that morning, just a few hours prior to arrival. Clearly, not information he wanted his wife to know. Fortunately, nothing happened, but it certainly drove home the point about history taking with family members present.
Mom steps out and you ask the patient about substance use. He continues to deny alcohol and illicit drugs. He says he doesn’t smoke. When you ask specifically about tobacco, he admits to vaping. Hmm. This is important, relevant information. The case is getting more interesting. We use x-rays judiciously in all patients, especially pediatric patients given the exposure to radiation. We don’t want to x-ray children, or adults for that matter, every time they have a cold or an asthma exacerbation. However, a history of vaping in any person with respiratory complaints, even mild, might mean an x-ray is indicated. Why? That's question number two.
Vaping increases the risk for which of the following diseases?
A. Legionnaires disease
B. Pneumonitis
C. Cystic fibrosis
D. Aspergillosis
Answer: B. Pneumonitis. Legionnaires and aspergillosis are infections, cystic fibrosis is a congenital disease. Pneumonitis is inflammation of the lungs. Let’s talk for a minute about vaping itself, then come back to the medical complications.
I know we have some smart kids and teens listening to the podcast. Today’s episode is especially for you, so you have the facts to continue making smart choices. Vaping is inhaling from an e-cigarette. The essential elements are a battery, an atomizer or heating element, and a cartridge of liquid, sometimes called ejuice. There are a number of different things you can vape, tobacco, marijuana, dabs which is butane hash oil, essentially more concentrated THC. People vape drugs of abuse, like meth and fentanyl.
What’s the difference between smoking and vaping? Smoking burns tobacco, resulting in exposure to nicotine smoke and chemicals like tar. These, as you are well aware, increase risks of heart disease and lung cancer. In contrast e-cigarettes heat up liquid nicotine. Users are exposed to two risks, tobacco and its addictive properties, and toxicity from the eliquid itself. What else is in these liquids? More on this in a minute, let's get back to our patient.
His X-ray comes back. You pull it up. Healthy lungs are black, ie filled with air. Our patient’s lungs contain patchy white spots, which the radiologist reads as scattered ground glass opacities. What does this mean? It’s a nonspecific finding and in my experience, it can mean just about anything. A CT scan might give us more information.
It is possible for atypical or viral pneumonias to cause this, as can other less common types of lung disease. But I think at this point we have a pretty good guess about what's happening. It’s most likely pneumonitis. The official name is EVALI. E-cigarette, or Vaping, Associated lung injury. Because there aren’t specific x-ray, CT or lab findings to diagnosis EVALI, it’s a diagnosis of exclusion. So, we should treat him with antibiotics just in case. EVALI is typically diagnosed by pulmonologists, after infectious causes are excluded via sputum cultures and other tests.
What's the treatment for EVALI? There’s no antidote. Care is generally supportive. Oxygen if needed, a ventilator if it progresses to respiratory failure which is possible. Lung transplants in a few cases. The mortality rate is estimated around 3%. Not especially high, but disturbing considering most of the patient are relatively young and healthy. Another treatment option are steroids to reduce inflammation in the lungs.
The e-cigarette industry, estimated to be a 22-billion-dollar industry, and growing worldwide, would like you to believe vaping is safer than smoking. Don’t believe the propaganda, remember Big Tobacco’s long history of lies and distortion of the facts. One ridiculous example is when an executive compared tobacco addiction to liking to eat gummi bears. This, in 1997. Vaping has only been prevalent for about 10 years, not long enough to determine its health impacts.
Big tobacco calls the youth their “replacement generation” an absolutely chilling name in my personal opinion. Vaping ads are targeted to adolescents. Unfortunately, successfully, more than two million middle and high school students were using e-cigarettes in 2023. The American Lung Association notes online sales make access easier and e-cigarettes come in a myriad of shapes and forms including toys and are disguised in innocuous looking things like jump drives, making them easy to hide. You’ve probably heard of the company called Juul, which at one point cornered 75% of the vaping market. 1 liquid nicotine pod contained as much nicotine as 1 pack of cigarettes. They had a huge presence on social media, and at one point almost half of their followers were teens ages 13-17.
Let’s talk about liquid nicotine, specifically a risk with vaping, rather than smoking. Flavored preparations contain flavoring and solvents to dissolve it and are especially popular with teenagers. It’s these ingredients, rather than nicotine itself, causing pneumonitis.
Question #3. What compound is responsible?
A. Vitamin E
B. Benzene
C. Cadmium
D. Unknown toxins
Answer is D. The truth is no one really knows. However, you are not wrong if you answered A-C. There is an association between pneumonitis and products containing Vitamin E. I say association, because it’s unclear if the Vit E is actually causing the problem.
In fact, we don’t even know what’s in the e-liquids, the ingredients aren’t listed and vary from manufacturer to manufacture. There are literally thousands of flavors. Things like bubblegum, cotton candy, berries, dessert flavors. Others sound less appealing like toast, blue cheese, milk, crab legs, and hot dogs.
What we do know about the fluids is they contain many potentially toxic compounds, not even counting nicotine. To list a few, they’ve been found to contain volatile compounds such as benzene and toluene, particulate matter, heavy metals, bacterial endotoxins, and fungal elements.
Let’s look at a few examples. First heavy metals, the liquids can contain lead, chromium and nickel. Interesting, exposure to heated chromium and nickel causes metal fume fever in welders. This is a respiratory illness similar to pneumonitis. Many flavored preparations contain diacetyl (or 2,3 butanedione). You may not remember this compound, but I bet you remember the news articles about it. It’s the butter flavored cause of “popcorn lung”, causing bronchiolitis obliterans in popcorn factory workers. At work we still have a sign on the microwave forbidding making popcorn, though this isn’t actually a risk. A clear cause of EVALI, as I said, hasn’t been identified, but I can guarantee none of these compounds are improving lung function.
No testing is required on these liquids before marketing. I don’t know about you, but I have only two lungs and I intend to use them both for at least 100 years. There’s no way I’d volunteer them as a petri dish for Big Tobacco. The FDA did ban flavored eliquid pods, but users switched to menthol, and manufacturers skirted regulations with various loopholes like disposable products.
Is the news about vaping all bad? No. A recent study in the New England Journal of Medicine suggested that electronic cigarettes may be helpful in smoking cessation.
Back to our patient. You admit him to the pediatric service. They continue antibiotics and order more test to exclude other causes of pneumonitis. The next morning, back on shift, you check his chart. Unfortunately, he decompensated overnight and is now in the pediatric ICU on a ventilator. Only time will tell if his lungs will recover or if he’ll become one of the 3% of patients who don’t.
Since watching and waiting isn’t our strong point, lets talk a little about nicotine toxicity in the meantime. I knew smoking was bad for you, I didn’t know 1 in 5 deaths annually in the US is attributed to smoking. That’s of course due to chronic nicotine exposure.
Acute nicotine toxicity is completely different. It’s uncommon in adults, well I should probably say used to be uncommon, but is on the one pill can kill list for kids. One cigarette, or three cigarette butts, ingested by a child is enough to cause significant toxicity.
What happens? Nicotine is an agonist, or stimulates, nicotinic receptors in the body. Low doses, like with smoking a cigarette, cause stimulatory effects including high blood pressure and heart rate, nausea, vomiting, dizziness and headache. At high concentrations, it causes the opposite effects, weakness and muscle paralysis. If you’ve been listening, you know the diaphragm is a muscle and when it’s paralyzed, you stop breathing and die.
Liquid nicotine preparations are much, much more concentrated than cigarettes. Children and pets have died from drinking these liquids. This problem is confounded by the potentially appealing taste of the flavors. You can’t really smoke enough cigarettes to do more than cause mild nausea and vomiting in an adult. Vape liquids are another story. Nic-sick is a relatively new term to describe effects of exposure to high nicotine levels, it’s a hashtag on tik-toc and other platforms. It describes the symptoms of acute nicotine toxicity after vaping too much. The liquids are concentrated enough to harm adults. People have committed suicide after ingesting or injected concentrated forms of liquid tobacco.
Green tobacco sickness is an interesting occupational illness affecting tobacco workers harvesting the plants in the field. Question #4 This illness is due to:
A. Pesticide exposure
B. Allergic reactions
C. Water on the leaves
D. Petroleum used to cure the leaves
Answer: C. Water on the tobacco plant leaves contains a high amount of nicotine, as much as 9 mg/ 100 mL or 1 Tablespoon. For reference, when you smoke a cigarette, it’s variable, but you get about 1 mg of nicotine. Green tobacco sickness is acute nicotine toxicity and workers have nausea, vomiting, dizziness and weakness. It’s preventable with PPE like gloves and dry clothing.
I came across an interesting case occurring in 2003 in Michigan. Almost 100 people became ill after eating ground beef from a particular supermarket. An investigation revealed an employee poisoned 200 lbs of meat with Black Leaf 40, an insecticide containing mostly nicotine. Fortunately, most of the symptoms were mild. Also think about this, when you smoke or vape, you’re inhaling a product used to kill bugs.
Back to our patient, after a few days on the ventilator, you’re relieved to see he’s extubated and doing well. He is receiving smoking cessation help and it’s expected he’ll make a full recovery. This is a fictional case, as are all our cases, to protect the innocent. But it is based on real poisonings that occur not infrequently.
Last question for today. Disney banned smoking in its own films in 2007 and for subsidiaries in 2015. What Disney movie is a toxicology jackpot showing hookah smoking, magic mushrooms, and erethism? If you’ve been listening this is an easy one!
A. 101 Dalmatians
B. Fantasia
C. Peter Pan
D. Alice in Wonderland
Follow our Twitter and Instagram feeds both @pickpoison1 and you’ll see the answer when I post it. Remember, never try anything on this podcast at home or anywhere else.
Finally, thanks for your attention. I hope you enjoyed listening as much as I enjoyed making the podcast. It helps if you subscribe, leave reviews and/or tell your friends.
All the episodes are available on our website pickpoison.com, Apple, Spotify or any other location where podcasts are available. Transcripts are available on the website.
While I’m a real doctor this podcast is fictional, meant for entertainment and educational purposes, not medical advice. If you have a medical problem, please see your primary care practitioner. Thank you. Until next time, take care and stay safe.