ACADEMIA Letters
Two Cases of COVID-19 in Adults who Vape
Rupal Shah MD MHPE, Karen Lien MD, Angela M. Cheung MD PhD, Jalal
Ebrahim MD, Shail Rawal MD MPH
The coronavirus disease 2019 (COVID-19) pandemic is a global public health emergency.
Available data suggest that older adults and those with comorbidities, two non-modifiable
determinants of health, are at greatest risk for death and requiring intensive care [1, 2].
Identifying modifiable risk factors for infection and severe disease could help inform interventions to curb the pandemic. We describe two cases of COVID-19 infection in young,
otherwise healthy adults who regularly used e-cigarettes.
Two patients presented to a hospital emergency department in Toronto, Canada on March
25, 2020. The first, a 45-year-old man with a 10-day history of non-productive cough, reported exertional dyspnea that had worsened over 48 hours. On further history, he endorsed
gastrointestinal upset with loose bowel movements. He was otherwise healthy and had travelled within Canada by plane in late February. Earlier that day, a 31-year-old woman with a
12-day history of non-productive cough and chills presented after 4 days of persistent chest
heaviness and dyspnea on exertion. Neither reported sick contacts or exposure to persons
known to have COVID-19. She had a history of mild childhood asthma that resolved before
10 years of age and depression controlled with Venlafaxine. Both patients endorsed daily
e-cigarette use with flavored nicotine; he vaped for 8 years and she vaped for 1 year after a
10-pack-year cigarette smoking history.
On assessment, he had a body temperature of 38.0°C and she was afebrile. Both patients were tachypneic and hypoxic; he required 3 liters per minute of supplemental oxygen
delivered by nasal cannula and she stabilized with 2 liters. Chest examination demonstrated
increased work of breathing and bilateral crackles on auscultation in both patients. He was
lymphopenic (0.7 x 109/L) with notable elevations in inflammatory markers including ferritin (1132 ng/mL), C-reactive protein (63 mg/L) and D-dimer (1141 ug/L); she was not
Academia Letters, October 2020
©2020 by Academia Inc. — Open Access — Distributed under CC BY 4.0
Corresponding Author: Dr. Rupal Shah, rupal.shah@uhn.ca
Citation: Shah, R., Lien, K., Cheung, A., Ebrahim, J., Rawal, S. (2020). Two Cases of COVID-19 in Adults
who Vape. Academia Letters, Article 2. 10.20935/AL2
1
lymphopenic (1.5 x 109/L) with milder elevations in the same inflammatory markers (ferritin 446 ng/mL; C-reactive protein 35 mg/L) except for a normal D-dimer. A high sensitivity troponin level was normal in both patients. Chest radiographs demonstrated bilateral
airspace consolidation with upper lobe predominance, more severe on his film. Nasopharyngeal specimens for the RdRp, envelope and nucleocapsid COVID-19 virus genes using
real-time polymerase chain reaction were obtained from both patients at the time of initial
assessment in the emergency department. His specimen results were available 38 hours after collection and detected RdRp and nucleocapsid COVID-19 genes; hers detected all three
genes 14 hours after collection.
Although these patients were presumed to have COVID-19 infection, empiric intravenous ceftriaxone and azithromycin were started to cover for possible community acquired
pneumonia. Within 12 hours of presentation, the man’s respiratory status deteriorated requiring intubation and mechanical ventilation. He was extubated on April 8th and was
discharged from hospital on April 21st without supplemental oxygen. She was gradually
weaned to ambient air by day 4 of admission and was discharged home on March 29th.
As observed in these two patients, acute worsening in respiratory status with COVID-19
infection typically begins 7 days from symptom onset [1]. However, the majority of patients
less than 55 years of age experience mild symptoms and do not require hospitalization unlike
the cases described [2]. We hypothesize that e-cigarette use may be associated with a greater
risk of acquiring COVID-19 infection and a more severe course of disease. In mouse models,
exposure to e-cigarette vapor has been shown to impair airway immune function in response
to inoculation with Streptococcus pneumoniae and influenza A [3]. E-cigarette liquid may
upregulate the production of interleukin-6 (IL-6), a pro-inflammatory cytokine [4]. This
could be relevant in COVID-19 infection, as higher IL-6 levels were seen in non-survivors
when compared to survivors [5].
The relationship between vaping and COVID-19 infection requires further exploration.
A recent US population-based cross-sectional survey of adolescents and young adults showed
that e-cigarette use and dual use of cigarettes and e-cigarettes are significant risk factors
for COVID-19 [6]; however, it is unclear whether those who contracted COVID-19 have
more severe disease. We recommend that cohort studies of patients with COVID-19 collect
data on e-cigarette use and examine associations with clinically important outcomes. Given
the increasing prevalence of vaping and emerging concerns about its impact on respiratory
health [7], better understanding of the potential role of e-cigarette use in COVID-19 infection
could help guide the public health response to this evolving pandemic.
Academia Letters, October 2020
©2020 by Academia Inc. — Open Access — Distributed under CC BY 4.0
Corresponding Author: Dr. Rupal Shah, rupal.shah@uhn.ca
Citation: Shah, R., Lien, K., Cheung, A., Ebrahim, J., Rawal, S. (2020). Two Cases of COVID-19 in Adults
who Vape. Academia Letters, Article 2. 10.20935/AL2
2
References
[1] Wang, D., Hu, B., Hu, C., et al. (2020). Clinical Characteristics of 138 Hospitalized
Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA,
323(11), 1061–9.
[2] Centers for Disease Control and Prevention (2020). Severe Outcomes Among Patients
with Coronavirus Disease 2019 (COVID-19) — United States, February 12 – March 16,
2020. MMWR Morb Mortal Wkly Rep, 69, 343–6.
[3] Sussan, T.E., Gajghate, S., Thimmulappa, R.K., et al. (2015). Exposure to electronic
cigarettes impairs pulmonary anti-bacterial and anti-viral defenses in a mouse model.
PLoS ONE 10(2), e0116861.
[4] Wu, Q., Jiang, D., Minor, M., Chu, H.W. (2014). Electronic cigarette liquid increases
inflammation and virus infection in primary human airway epithelial cells. PLoS ONE,
9(9), e108342.
[5] Zhou, F., Yu, T., Du, R., et al. (2020). Clinical course and risk factors for mortality of
adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet
395(10229), 1054–62.
[6] Sindelar, J.L. (2020). Regulating Vaping — Policies, Possibilities, and Perils. N Engl J
Med. DOI: 10.1056/NEJMp1917065
[7] Mathur, S.G., Cheng, J., Halpern-Felsher, B. (2020). Association between youth smoking, electronic cigarette use, and COVID-19. J Adolesc Health, 67(4), 519-523.
Academia Letters, October 2020
©2020 by Academia Inc. — Open Access — Distributed under CC BY 4.0
Corresponding Author: Dr. Rupal Shah, rupal.shah@uhn.ca
Citation: Shah, R., Lien, K., Cheung, A., Ebrahim, J., Rawal, S. (2020). Two Cases of COVID-19 in Adults
who Vape. Academia Letters, Article 2. 10.20935/AL2
3