Vaping — don’t do it until we know more

If you have kids, I’d advise them to stop vaping entirely until we know more. Here’s why — granted that there have been ‘only’ several hundred cases of ‘lung injury’ and a few deaths  in a 300+ million population, but in any new illness (AIDs, SARs, Legionnaire’s diseases) only the most severe cases are seen first.  

Addendum 19 Mar — from PNAS – When exposed to high temperatures in a vaping device , vitamin E acetate can release the very toxic gas ketene CH2 = C = O which has been shown (in animal studies, dosage not given) to damage the lungs and impair the central nervous system

This is exactly the way it was with AIDs, the first few cases seroconverting (showing they’d been infected with the virus) had their immune system collapse almost immediately after infection.  As time wore on, we’d see seroconverters who remained healthy for 1 year, 2 years, 5 years, because (for reasons we still don’t understand) they were resistant to the virus or had a stronger immune system.  But eventually they got sick and died as well.

So it is with vaping related lung illness.  How many more cases we’ll see in  more resistant individuals in the coming years isn’t known. Will we have a nation of 30 year olds crippled with chronic lung disease?  Unlike AIDS, SARS or Legionnaire’s disease where there is a single organism, there are thousands of vaping products, and what people are putting into the machines is completely unknown.  Perhaps it’s just one drug.  Perhaps it’s a contaminated drug.  Perhaps its the particular machine.  At this point we don’t know.  It’s just like the early days of the AIDs epidemic — plausible theories abound and reliable data is scarce.  I was practicing medicine when AIDs came out in the late 70s and it was scary as hell, not knowing what was causing it.  At least with this we’re pretty sure it’s the vaping, given the age distribution and the positive histories in all.

We have one excellent example of a genetic condition predisposing to lung disease — alpha1 antitrypsin deficiency predisposes to emphysema and chronic obstructive pulmonary disease  — https://en.wikipedia.org/wiki/Alpha1_antitrypsin.  It would be useful  to see how many of the vaping cases have this deficiency.

This just in – according to the Wall Street Journal 2 hours ago 31 October ’19 ago the CDC says there have been 1,888 cases with 37 deaths.  Hopefully this is NOT the tip of the iceberg  — but probably it is.

Addendum 1 Nov ’19 I wrote this to a niece who has an 18 year old daughter entering college.  She is a teacher in a standard American high school (not in the ghetto, not filthy rich).  If any one has boots on the ground she does. Her response:  “Yes it’s very common in high school” — scary.

Addendum 8 Nov ’19  — The following comment by Peter Shenkin is so important that it belongs in the body of the blog proper —

It’s pretty impressive, but these are early times in the investigation.

Peter Shenkin commented on Vaping — don’t do it until we know more

If you have kids, I’d advise them to stop vaping entirely until we know more. Here’s why — granted that there have been ‘only’ …

You wrote: “Vaping — don’t do it until we know more”

We now know more; source of the following quote is at the end.

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“CDC Announces “Major Breakthrough” that I Recognized and Reported Two Months Ago; Outbreak is Almost Certainly Not Associated with Legal Nicotine Vapes
Minutes ago, the Centers for Disease Control and Prevention (CDC) announced what they called a “major breakthrough” in its investigation of the vaping-associated respiratory illness outbreak. They tested lung tissue samples from 29 case patients and all 29 (100%) were found to contain vitamin E acetate oil.

This finding does represent a major breakthrough for four reasons:

1. The vitamin E acetate oil was detected in the actual lung tissue of the case patients.

2. The vitamin E acetate oil was detected in every single one of the lung tissue samples from these 29 case patients.

3. The samples came from 10 different states, confirming that the outbreak seems to have a common cause, rather than geographic variation.

4. Three of the patients whose lung samples revealed vitamin E acetate had reported using only nicotine-containing products, thus confirming that there is significant under-reporting which may explain why about 11% of the patients do not report vaping THC.”

The above quote is from: https://tobaccoanalysis.blogspot.com/2019/11/cdc-announces-major-breakthrough-that-i.html.

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Full disclosure: Michael Siegel, a Public Health and Epidemiology doc who writes this blog, is my first cousin once removed. In another blog entry, he lambasts the FDA for disallowing mint vaping liquids while giving cigarette companies a pass on mint-flavored cigarettes.

What is legionella trying to tell us?

10 years out of Med School, a classmate in the Public Health service had to deal with the first recognized outbreak of Legionnaire’s disease, at the Bellevue Stratford hotel in Philly, about one air mile from Penn Med where we went.   The organism wasn’t known at the time and caused 182 cases with 29 deaths.  We’ve learned a lot more about Legionella Pneumophila since 1976 and the organism continues to instruct us.

The most recent lesson concerns one of the 300 or so proteins Legionella injects into a cell it attacks.  This is remarkable in itself.  The organism uses them to hijack various cellular mechanisms to build a home for itself in the cell (the LCV — Legionella Containing Vacuole).  Contrast this with diphtheria which basically uses one protein (diphtheria toxin) to kill the cell.

One of the 300 proteins is called SidJ and looks like a protein kinase (of which our genome has over 500).  However [ Science vol. 364 pp. 787 – 792 ’19 ] shows that SidJ carries out a different different reaction.SidJ is activated by host-cell calmodulin to polyglutamylate the SidE family of ubiquitin (Ub) ligases inhibiting them. Crystal structures of the SidJ-calmodulin complex reveal a protein kinase fold that catalyzes ATP-dependent isopeptide bond formation between the amino group of free glutamate and the gamma carboxyl group in the catalytic center of SidE a ubiquitin ligase.   This, instead of just esterifying the hydroxyl group of serine or threonine or tyrosine with the terminal phosphate of ATP as a kinase is supposed to do.

Why is this important? The only protein known to have polyglutamic acid added to it is tubulin, the protein from which microtubules (neurotubules to the neurologist).  The work is important because some of the 500+ protein kinases in our genome might be doing something else.  Has the chemistry each and every member of the group been studied?  Probably not..

The authors close with “In summary, our results underscore the diversity and catalytic versatility of the protein kinase superfamily. We propose that ATP-dependent ligation reactions may be a common feature among the vast diversity of eukaryotic protein kinase–like enzymes found in nature (25). There are more than 500 protein kinases in humans and our results suggest that they should be ex- amined for alternative activities.”

I couldn’t agree more.