Letter-to-the-Editor:

Lipoid Pneumonia; An Unforeseen Consequence of Inappropriate Electronic Cigarette Use

P Caponnetto1, CM Bruno1,2 and R Polosa1,2


1Centro per la Prevenzione e Cura del Tabagismo (CPCT), Azienda Ospedaliero-Universitaria “Policlinico-V. Emanuele”, Università di Catania, Catania, Italy; 2Institute of Internal Medicine, Azienda Ospedaliero-Universitaria “Policlinico-V. Emanuele”, Università di Catania, Catania, Italy.

Address correspondence to:
Prof. Riccardo Polosa, MD, PhD
UOC di Medicina Interna
Edificio 4, Piano 3
AOU ‘‘Policlinico-V. Emanuele’’, Universita` di Catania, Italy.
Via S. Sofia 78
95123 Catania
ITALY
polosa@unict.it


Word count: 367


Exogenous lipoid pneumonia is a rare condition that may occur from aspiration or inhalation of fatlike material, such as mineral oil found in commercial products and various aerosolized industrial materials. In fact, lipoid pneumonia has been reported after excessive or inappropriate use of oil-based laxatives, lip balm and flavoured lip gloss.

McCauley et al (1) add electronic cigarette use to the list of potential causes of exogenous lipoid pneumonia. They document the intriguing case of a 42-year-old-woman with lipoid pneumonia and speculate that this could have been resulted from the regular exposure to glycerine-based oils found in electronic cigarette vapour.

For a balanced interpretation of this case report, it is worth emphasizing that this patient also had a schizoaffective disorder for which she was taking multiple psychiatric medications. Schizoaffective disorder is a mental illness characterized by recurring episodes of mood disorder and psychosis. These are known to be associated with eating disorders, odd behaviours, and suicidality related to delusional ideas or distorted cognitions related to food or body perception (2,3). These patients have been described to ingest coins, glycerin soap, urine, flowers, glycerin suppositories, candles, or inhale dangerous substances. Therefore, the lipoid pneumonia of this psychiatric patients might have been due to inappropriate ingestion of glycerine-based oils in the e-liquid of her electronic cigarette. In a follow up of hundreds of regular users of electronic cigarette with prefilled cartridges (containing a small cotton roll soaked in glycerine-based nicotine solution) no major adverse event were reported to date (4-7). Thus, the case reported by McCauley et al (1) simply indicates that harm can be caused by electronic cigarettes when these products are not used as recommended by the manufacturers.

It also interesting to note that "the patient reported a recent exposure to fumigation chemicals, as the result of a bedbug infestation of her apartment building 2 weeks prior to
her hospitalization." Although causality (or con-causality) cannot be proven for certain, the temporal relationship of the clinical symptoms with the reported exposure of fumigation chemicals should be also considered in this case report. New generation fumigation chemicals include crude essential oils (8,9). Therefore, a role of these products for her lipoid pneumonia cannot be discounted.



References.
1.	McCauley L, Markin C, Hosmer D. An unexpected consequence of electronic cigarette use. Chest. 2012 Apr;141(4):1110-3.
2.	Goldstein G, Haas GL, Pakrashi M, Novero AM, Luther JF. The cycle of schizoaffective disorder, cognitive ability, alcoholism, and suicidality. Suicide Life Threat Behav. 2006 Feb;36(1):35-43.
3.	Correll CU. Understanding schizoaffective disorder: from psychobiology to psychosocial functioning. J Clin Psychiatry. 2010;71 Suppl 2:8-13.
4.	Polosa R, Caponnetto P, Morjaria JB, Papale G, Campagna D, Russo C. Effect of an electronic nicotine delivery device (e-Cigarette) on smoking reduction and cessation: a prospective 6-month pilot study. BMC Public Health. 2011;11:786.
5.	Efficacy and safety of an electronic nicotine delivery device (E-cigarette). http://clinicaltrials.gov/ct2/show/NCT01164072?term=electronic+cigarette&rank=1
6.	Efficacy and safety of an electronic nicotine delivery device (E-cigarette) without nicotine cartridges. http://clinicaltrials.gov/ct2/show/NCT01194583?term=polosa&rank=2
7.	A structured protocol to evaluate efficacy and safety of a popular electronic nicotine delivery device (E-cigarette). http://clinicaltrials.gov/ct2/show/NCT01188239?term=polosa&rank=3
8.	Keita SM, Vincent C, Schmit J, et al. 2001
9.	Shaaya E, Ravid U, Paster N, et al 1991