Here is what I have found so far. Best wishes to those affected.
[Dr. Aberegg]…professor of pulmonary and critical care medicine told MedPage Today that he now believes there are at least three distinct manifestations of vaping-associated* pulmonary injury: lipoid pneumonia, cryptogenic organizing pneumonia, and alveolar hemorrhage syndrome.
*carts and rigs
It doesn’t seem to me like alpha-tocopherol, or its acetate (Honey Cut) caused this. There are many factual and statistical reasons to back up my position, but the four most powerful are: vitamin E was not found in all tested samples (so it’s not a common factor), at least one patient reported the cart he purchased was watery and pee colored (making him suspicious), lipoid pneumonia was reported in most patients, and some patients reported falling ill within a day or two of vaping a suspect cart.
Alpha-tocopherol is amber/reddish and very thick, and alpha-tocopherol acetate (Honey Cut) is clear in small amounts and very very thick. Therefore, neither of them would fit the description as a cutter used in the watery and pee-colored cart. And, tocopherol isoforms of vitamin E like alpha-tocopherol and its acetate are not fats (a type of lipid), so they cannot cause lipoid pneumonia. Lastly, alpha-tocopherol has been used in e-cig vape juice for years as an antioxidant, and, like Dr. Aberegg I would have expected cases to appear months ago if they are caused by a-tocopherol isoform, considering Honey Cut (alpha-tocopherol acetate) has been available since before 01/01/2019, when it first appeared in Los Angeles, California, but, the first cases were not reported until 06/28/2019, in Wisconsin and Illinois of all places.
I have yet to find one study that finds vaporized/aerosolized/ nebulized/supercritical alpha-tocopherol and its acetate damage the lungs. To the contrary, all the studies found they reduce oxidative damage and lung inflammation. Supercritical vitamin E means the air is so thick with tocopherol that it’s almost wet.
We also must consider the microfluidics and physics of vapor as its inhaled from a vaporizer. From the research I came across, most of the nicotine in an e-cig is absorbed by the mouth and throat. So, considering tocopherol isoforms are larger molecules than nicotine, it stands to reason that most of the alpha-tocopherol and its acetate would be absorbed in the mouth and throat, with lower amounts entering the lungs.
It is my opinion that any mention of vitamin E oil in vape carts by doctors and lab techs in news articles, besides the new Leafly article which seems like fear mongering, is referring to vitamin E-rich vegetable oil like corn, soy, or sunflower vegetable oils. I highly doubt vitamin E isoforms are what the news articles are referring to. In fact, I would bet the black market cart makers at fault are using vegetable oil as a diluent. Vitamin E-rich vegetable oils contain a mix of all vitamin E isoforms, including gamma.
So far, the topic of vitamin E as the culprit is mainly being discussed by Dr. Pirzada, in this thread, and in the Leafly article by David Downs. I only found a couple of news articles discussing vitamin E oil in the carts, where I also found Dr. Pirzada. For example, it was reported that nearly all suspicious carts tested in NY had vitamin E oil, but they also had THC, and I’m sure many other common compounds.
Dr. Pirzada claims vitamin E oil can cause lipoid pneumonia. However, considering pure a-tocopherol and its acetate are not fats, she must be referring to the oil that contains mixed vitamin E isoforms and fatty acids, such as corn, soy and sunflower vegetable oils.
I am betting the cause is mineral oil as a diluant (watery to thick, colorless, and causes lipoid pneumonia), and/or vegetable oil as a diluent (pee colored, watery, and causes lipoid pneumonia), and/or excessive toxic flavorings (like diacetyl, synthetic vanillin, and cinnamaldehyde), and/or very hot vape element or wax-shatter nail/rig causing terps to degrade into benzene and methacrolein (similar to acrolein, a carcinogen and powerful pulmonary irritant, causing acute lung injury and pulmonary edema), and/or a new synthetic cannabinoid to goose the % THC like from the Dark Web (or China), and/or some newly used and untested chemical (like from Alibaba or Indiamart), and/or poor quality industrial grade PG or PEG with heavy metals (which at high temps convert into formaldehyde and benzene). Similar symptoms have been found in e-cig users in years past.
Due to the limited number of outbreaks in random states with clusters of limited patient numbers, with around 250-325 suspected cases total from at least 3 different fake cart brands, it seems to me this is the action of one person, or a drug gang, that made a batch and is selling it online, over state lines, possibly through the Dark Web on a drug marketplace. But what do I know? I’m prone to conspiracies lol.
Go to the end of this post for math regarding cart numbers and stats for total suspected cases relative to a-tocopherol acetate usage.
NEWS, FACTS & RESEARCH:
(current as of 09/02/2019 5 PM west coast time)
Dylan Nelson doesn’t remember anything leading up to his ordeal, not even arriving at the hospital. His first memory is of waking up from the coma intubated in his hospital bed.
“It was very uncomfortable. Every time I would cough with the tube in my mouth, fluid would come up out of my lungs into the tube and they would have to vacuum out the hose,” he remembers.
He says he put it together that vaping was part of what led to his hospitalization. Doctors told him about other cases similar to his own. He says he had been vaping THC oil from a cartridge he bought for cheap from a friend.
"The oil in the cartridge was really watered down. And it was pee-colored, it wasn’t supposed to be that color, it’s supposed to be dark amber," he says.
https://www.medpagetoday.com/pulmonology/smoking/81924
Vaping Disease Manifestations
John E. Parker, MD, of West Virginia University in Morgantown, was among the first clinicians in the country to warn of the potential for vaping-related lung injury after diagnosing lipoid pneumonia in a 31-year-old female e-cigarette user in acute respiratory distress.
The professor of pulmonary and critical care medicine told MedPage Today that he now believes there are at least three distinct manifestations of vaping-associated pulmonary injury: lipoid pneumonia, cryptogenic organizing pneumonia, and alveolar hemorrhage syndrome.
“I just saw a 19-year-old young man in the clinic yesterday with a 30-pound weight loss, two seizures, and evidence of some respiratory disease,” he said.
Early in August, the FDA reported that it had received 127 reports of seizures or other neurological symptoms occurring between 2010 and 2017 and that it is investigating “to determine if there’s a direct relationship” between the use of e-cigarettes and the incidents.
Aberegg said he also believes lipoid pneumonia is just one of several lung disorders that can be linked to vaping.
“The reason we jumped to that one, perhaps prematurely, is because we’re finding abnormal immune cells in samples from patient’s lungs that show evidence of lipid materials,” he said, adding that this occurs with several different lung diseases.
“For me, the main importance of that finding is that it suggests the immune system is being revved up,” he said.
“States are completing their own investigations and verifications of cases based on CDC’s recently released standardized case definition,” the Friday statement says.
Health officials say it’s unclear whether there’s a connection between cases, whether vaping definitively caused these illnesses and what components or chemicals of e-cigarettes might be responsible.
“Regardless of the ongoing investigation, e-cigarette products should not be used by youth, young adults, pregnant women, as well as adults who do not currently use tobacco products,” the CDC and FDA said.
The CDC, FDA and state health departments say they’re working together figure out which products might have been used and facilitate laboratory testing.
So far, the FDA has “received about 80 samples and continues to receive requests from states to send more samples for the FDA to analyze,” the statement says. “The samples represent a variety of different types of products and substances — a number of which contained incomplete information about the product.
“At this time, there does not appear to be one product involved in all of the cases, although THC and cannabinoids use has been reported in many cases.” THC, or tetrahydrocannabinol, is the psychoactive substance within cannabis.
In Wisconsin, health officials said Thursday that a majority of the cases in their state had inhaled THC products. Health officials in the state have issued stern warnings to residents: Stop vaping immediately.
The surge in cases may be the result of something recently added to the oils “to dilute or add to them,” said Scott Aberegg, a University of Utah hospital pulmonologist and critical care specialist, who cared for Mitchell and four other patients at his hospital and consulted on two others at another facility.
Some of the patients had vaped for months and years, he said, so if there had been a previous cluster of cases, “we would have recognized it earlier.”*
Mitchell said he has little recollection of what happened while he was in the hospital since he was in a medically induced coma for much of the time. But he is stunned that doctors attribute his near-death experience to vaping — a practice he began about two years ago because he wanted to quit conventional cigarettes.
“It’s promoted as healthier,” he said.
Mostly, he said he vaped flavored nicotine products but has used THC a few times with friends, he said. None of them has gotten sick.
In mid-June, Mitchell said he bought a different brand of vape juice — peach menthol flavor — from his regular vape shop and used it with his same e-cigarette device. It was the first time he used a well-known brand. The family did not want to identify it until the FDA investigates further. “It was a brand new box,” Mitchell recalled. Inside, “the bottle had a seal.”
He said he vaped less than usual that time. The next day, he felt sick and began his life-changing medical odyssey.
*Dr. Aberegg is correct and astute. The math section of this post will lay out why his point is essential when considering alpha-tocopherol acetate (Honey Cut).
https://www.cbsnews.com/news/milwaukee-health-department-warning-stop-vaping-immediately-2019-08-29/
The exact cause has yet to be determined.
But in an ongoing state investigation among all ages of those with lung disorders who reported vaping, 89% said they inhaled THC products in the form of waxes or oils. THC is the active ingredient in marijuana.
https://www.politico.com/story/2019/08/27/vaping-lung-disease-regulation-1686396
Irfan Rahman, a researcher at the University of Rochester Medical Center, suspects that the main cause is the oil used as a suspension for many vaping products, including nicotine, THC or another popular marijuana component, CBD, producing a disease called lipoid pneumonia. Since e-cigarette manufacturers have not filed applications with FDA yet, it’s difficult to know how many nicotine-based products use these oils and which could be most problematic. A January medical journal article, for instance described a case of severe lung illness linked to butane hash oil that bears a strong resemblance to the current spate of cases across the country.
…
Lung injury from inhaling butane hash oil mimics pneumonia - PMC
A previously healthy 18-year-old female presented to the ED with shortness of breath for 3–4 days. Initial oxygen saturation was 79% on room air. She was refractory to bronchodilators, steroids and supplemental O2. She has a 1-pack year smoking history and daily BHO abuse. Chest x-ray was positive for bilateral patchy infiltrates with mild hyperinflation. CT was negative for Pulmonary Embolus or other acute pathologic process. Sputum gram stain and blood cultures were negative. Arterial blood gases confirmed a pO2 of 73 mmHg. On physical exam she was tachycardic and tachypneic. Respiratory auscultation showed decreased air entry bilaterally with diffuse expiratory wheezing, bilateral rhonchi and a prolonged expiratory phase. We concluded her severe pneumonitis was secondary to daily BHO inhalation.
We hypothesize a mechanism of lung injury and acute respiratory failure secondary to inhalation of high levels of methacrolein and benzene related to relatively novel phenomena of BHO use.
Our patient described her process of inhaling BHO with the use of a “Maverick” glass water pipe, 4-5-inch-long titanium cylindrical piece known as a “nail”, a propane blow torch and a small metal wire to hold the dab. The nail would be heated with the propane blow torch until it became bright red in color; temperatures ranging from 900 to 1075°F [3]. A dab of BHO on the end of the metal wire would then be touched against the nail causing an instant vaporization. The heated vapor would then be inhaled through the top of the pipe.
At approximately 978°F high levels of terpene, which are aromatic oils found in cannabis [3], degrade into various byproducts; of most importance are the noxious irritants Methacrolein and Benzene [4]; both known carcinogens. Methacrolein has been shown to be structurally similar to Acrolein, a powerful pulmonary irritant and carcinogen [3]. Studies have shown that high levels of Acrolein can lead to acute lung injury and pulmonary edema in laboratory animals [3].
We propose our patient developed an acute lung injury after she heated the nail to a temperature most likely exceeding 900°F; as she stated she would heat the nail until it was bright red. At this temperature, there was likely an increased release of the pulmonary irritants Methacrolein and Benzene, as well as hot vapor [3]. The patient also stated the BHO was not purchased legally, indicating that the level of butane in the product was unknown. There is a likely probability that a high level of inhaled butane also contributed to her symptoms.
The only literature on this subject matter we could find involved a 19-year-old male in 2016 whom was diagnosed with severe pneumonitis after inhalation of butane hash oil [5]. Commonalities in these two cases are summarized in Table 1, previous case clinically more severe, both clinical courses were similar with response to respiratory support and steroids.
Fake THC Carts Are Sending People to the Hospital
Lab testing of Pirzada’s patient’s cartridge revealed that it tested positive for not just THC, but also vitamin E. If inhaled, oils like Vitamin E can cause lipoid pneumonitis*, a rare condition that results from fat particles being inhaled into the lungs, says Pirzada. When she submitted the results to the Department of Health, it informed her that there were two other cases of THC cartridges testing positive for vitamin E oil, though she says the cartridge is currently being retested for other substances.
*No, vitamin E cannot cause lipoid pneumonitis (lipoid pneumonia) because it’s not a fat (a type of lipid), which is required to produce lipoid pneumonitis. Dr. Pirzada must be referring to the oil that contains vitamin E (if pure tocopherol isoform is not used), such as soy and sunflower vegetable oils.
MN health officials see vaping link to severe lung injuries
ONE MAN’S STORY *
On July 21, Dylan Nelson, 26, of Burlington, Wis., opened a new e-cig vial and took a few hits. Shortly after, he began to feel ill. He developed a fever and spent a restless night, tossing, turning and sweating.
At 6 a.m., his sister took him to the emergency room. Twelve hours later, he was in a coma.
“He just kept getting worse and worse,” said his brother Patrick DeGrave, who spent the next week by his bedside wondering if he would live or die.
“His lungs began filling up with fluid,” DeGrave said. “They were running tubes down his mouth and throat into his lungs. They drained multiple canisters of fluid from his lungs. The doctor said his heart looked like the heart of a 65- to 70-year-old person.”
Nelson ran a continuous fever sometimes as high as 104 degrees. DeGrave would wipe his forehead, and within 10 seconds, he said, his brother’s head looked like it had been dunked in water.
“I had to start preparing for the worst,” he said. “I would ask the doctors, ‘Is my brother going to make it out of here?’ ” He was told, “We can’t be sure”; “It doesn’t look good”; and “If you’re a religious person, now would be a good time to start praying.”
After a day in a coma, the doctors tried reviving him, but his heart started beating so wildly, they sedated him, fearing blood clots would cause other damage.
Two days later, he woke up and by the end of a week, he was able to leave the hospital.
DeGrave’s theory is his brother just got a bad vial. He didn’t think it was an accumulation of vaping, as some have suggested.
*This guys def was vaping THC, but he’s claiming it was e-cig to avoid legal issues. Note the reported rapid onset.
https://www.medpagetoday.com/pulmonology/smoking/81785
John E. Parker, MD, was working at a West Virginia hospital in 2015 when a 31-year-old female patient was admitted with acute respiratory problems. A team of doctors ultimately suspected that her mysterious case of lipoid pneumonia might be related to vaping and weren’t sure they had seen anything like it before. They were intrigued enough to publish a case report. Such reports on unusual or provocative patient findings can serve as a call to the medical community to be on the lookout, though they sometimes raise more questions than they provide answers.
This summer, almost 4 years later, federal officials began investigating a national outbreak of severe lung illnesses linked to vaping that has struck more than 150 patients in 16 states. In an interview, Parker, a professor of pulmonary critical care and sleep medicine at West Virginia University, described what happened.
https://www.nytimes.com/2019/08/31/health/vaping-marijuana-ecigarettes-sickness.html
While e-cigarettes have been presumed less harmful over the long run than cigarettes, the ultimate impact from years of vaping is simply not yet known.
Mr. Eissenberg, director of the Center for the Study of Tobacco Products at Virginia Commonwealth University, said seven cases of similar lung injuries from e-cigarette vaping had been reported in previous years.
“A common ingredient was vegetable glycerin, which is made from vegetable oil,” he said. “If there is some incomplete process, there can be oil left in the vegetable glycerin when that person is using it, and inhaling oil and getting oil into your lungs is what is causing some of the lung injuries we see.”
Transcript of August 23, 2019, Telebriefing on Severe Pulmonary Disease Associated with Use of E-cigarettes
https://www.cdc.gov/media/releases/2019/t0823-telebriefing-severe-pulmonary-disease-e-cigarettes.html
https://bdsanalytics.com/wp-content/uploads/2019/06/Concentrates-Exec-Summ.pdf
https://www.inc.com/will-yakowicz/marijuana-sales-2016-50-billion.html
Some e-cigarette ingredients are surprisingly more toxic than others
Acute Lipoid Pneumonia Secondary to ECigarettes Use: An Unlikely Replacement for Cigarettes
http://sci-hub.tw/10.1378/chest.2274860
Acute Effects of Electronic Cigarette Aerosol Inhalation on Vascular Function Detected at Quantitative MRI
https://pubs.rsna.org/doi/10.1148/radiol.2019190562
E-liquid Database
https://eliquidinfo.org/
Tocopherol as Treatment for Lung Injury Associated With Burn and Smoke Inhalation
http://sci-hub.tw/10.1097/BCR.0b013e3181923bf3
Supercritical Fluid Aerosolized Vitamin E Supplementation
http://sci-hub.tw/10.1385/1-59259-030-6:209
Two Faces of Vitamin E in the Lung
https://www.atsjournals.org/doi/full/10.1164/rccm.201303-0503ED
Santa Cruz Biotech SDS: alpha tocopherol acetate
'http://datasheets.scbt.com/sc-214934.pdf
The material is not thought to produce either adverse health effects or irritation of the respiratory tract following inhalation (as classified using animal models).
Making Cosmetics SDS: alpha tocopherol acetate
'http://www.makingcosmetics.com/msds/sds-vitamin-e-dl-alpha-tocopheryl-acetate.pdf
Inhalation: Not expected to be irritant.
MATH ESTIMATES, FACTS, & CONSERVATIVE ASSUMPTIONS FOR BLACK MARKET:
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Honey Cut has been available since before 01/01/2019, first appearing in L.A., California, by California Laboratories (not a real company).
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The CDC puts the start date of the outbreak of cases on 06/28/2019, in Wisconsin and Illinois.
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The CDC states California has had cases as of 08/22/2019, and the CBS L.A. affiliate claims the first cases in Ventura County were reported very close to that date.
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Legal cannabis vape market estimate for 2019: $2.6 billion
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Ratio of U.S. cannabis black market size (billions) to legal market size (2016): 6.72
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Retail black market 1ml cart price: $50
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Honey Cut in 1ml cart: 0.5ml
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% of black market carts using alpha-tocopherol acetate (this is low): 25%
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Number of suspected cases reported by month, averaged over two-months from 06/28/2019 to 08/28/2019: 163
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So, $2.6B x 6.72 = $17.5B as estimated 2019 black market vape sales. Then, $17.5B / $50 / 12 = 29.1667 million carts sold per month in 2019. And, 29.1667M * 0.25 = 7,291,675 carts sold per month containing alpha-tocopherol acetate (Honey Cut).
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Finally, 163 suspected cases per month / 7,291,675 carts with Honey Cut sold per month * 100 = therorically, 0.002235426016656% of alpha-tocopherol acetate users would report symptoms under discussion if a-tocopherol acetate is the cause (assuming each cart sold = 1 unique person).
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So, I would say it’s extremely unlikely a-tocopherol isoform or its acetate are the culprit, even if we are only discussing contact allergic reactions (which is very rare for a-tocopherol acetate).