Thromboembolism Triggered by a Combination of Electronic Cigarettes and Oral Contraceptives: A Case Report and Review of Literature

Abstract

Genetic predisposition, oral contraceptive (OCP) use, tobacco smoking, cancers, and trauma are well-known triggers for hypercoagulability and thromboembolism. Multiple reports have been published on the health risk of combining OCP and traditional cigarettes smoking in the context of thromboembolism. However, limited information is available on the health consequences of combining OCP use with electronic cigarettes. Here, we report a case of a young female patient with a past medical history of ovarian cysts and electronic cigarettes use who came into the hospital with a complaint of “recurrent seizures” and tachycardia. This patient was subsequently diagnosed with bilateral pulmonary emboli, subacute cerebrovascular accident (CVA), and possible patent foramen ovale. Therapeutic Lovenox was initiated. Reasons to educate young females on the risks of combining OCP and electronic cigarettes use were explained.

Introduction

Several cases of malignant neoplasm and lung diseases have been linked to cigarette smoking. ¹ Furthermore, tobacco smoking constitutes an important risk factor for the development of cardiovascular diseases (CVDs). ² Consequently, significant public health resources have been allocated and deployed to help tobacco smokers quit smoking. Further attempt to reduce known devastating effects of traditional tobacco smoking has resulted in the development and marketing of electronic cigarettes or vaping. Electronic cigarettes, colloquially known as vaping devices, are a type of system that entails the delivery of nicotine in an arrangement powered by a battery. ³ Currently being marketed as “healthy substitute” for traditional cigarettes use, electronic cigarette has gained wide acceptance among young adults.^4,5 However, recent studies have shown that electronic cigarettes may cause thrombosis and lung injury. Therefore, the use of electronic cigarettes by patients who are currently exposed to other triggers for hypercoagulability may accelerate thromboembolism. This becomes instructive because most young females indulging in the use of electronic cigarettes are also on oral contraceptives (OCP) for diverse reasons. We hereby report a case of a 22-year-old woman who was diagnosed with bilateral pulmonary emboli and subacute CVA while on OCP and using electronic cigarettes.

Case Presentation

A 22-year-old woman with a past medical history of ovarian cysts and electronic cigarettes use came to the emergency room (ER) after having “recurrent seizures.” The patient was tachycardic on presentation. Initial labs revealed low hemoglobin and elevated D-dimer. Her urine drug screen was unremarkable. The result of computed tomography angiography (CTA) head and neck was unremarkable for any acute process. Electroencephalogram did not show any epileptiform abnormalities. Magnetic resonance imaging (MRI) of the brain revealed subacute infarction in the right cerebral hemisphere (Figure 1). Of note, the patient was on OCP for birth control before admission. Venous Doppler ultrasound of the lower extremities did not show deep vein thrombosis. Results of CTA chest were significant for small bilateral pulmonary emboli more evident in the left lower lobe of the lung (Figure 2). The patient initially received Keppra, aspirin, and Plavix. Hypercoagulable workup was initiated by the oncology team. Results for antithrombin deficiency, protein C or S deficiency, factor V Leiden, and prothrombin G20210A gene mutation were all unremarkable. Rheumatology workup was unrevealing. Transesophageal echocardiography showed slight aneurysmal changes in the interatrial septum with possible trace shunt as revealed by the color flow Doppler. Therapeutic Lovenox was initiated while Plavix and Keppra were discontinued. Fortunately, the patient remained symptom-free and was subsequently discharged from the hospital. She was asked to continue Eliquis for 6 months and follow up with hematology-oncology and cardiology. After the exclusion of organic causes, a combination of OCP and electronic cigarettes use was considered as the etiology for diffuse pulmonary emboli and subacute CVA in the context of possible patent foramen ovale.

Figure 1.

MRI brain showing subacute infarct in the right cerebral hemisphere.

Figure 2.

CTA chest showing pulmonary emboli in the left lower lobe of the lung.

Discussion

Electronic cigarette use, currently being marketed as a safe alternative to traditional tobacco smoking, has gained appreciable acceptance among adolescents and young adults. ⁶ By 2018, over 3.6 million young Americans are already using electronic cigarettes. ⁷ As a result of this widespread use, diseases like E-cigarette or vaping use-associated lung injury (EVALI), bronchiolitis, lipoid pneumonia, hypertension, CVDs, stroke, seizures, and thrombotic coagulopathy have been seen and documented. In fact, by February 2020, over 2000 cases of EVALI have been reported with 68 confirmed deaths in the United States. ⁸ Despite paucity of data on the enduring effects of electronic cigarettes, some active components of vaping devices can modify the arterial walls of blood vessels and thereby trigger CVDs.^9,10 Both animal and human studies have consistently shown that short-term exposure to electronic cigarettes could enhance platelets aggregation and elevate the risk of thrombosis.^11,12 Also, more studies have revealed that electronic cigarettes use could result into cardiovascular complications. ¹³ It is therefore not surprising to see thrombotic and embolic events in patients indulging in the use of electronic cigarettes. Harada et al. ¹⁴ documented a case of EVALI and thrombotic coagulopathy in a 20-year-old man who had a history of electronic cigarettes use. This patient presented to the ER with hemoptysis, shortness of breath, and subjective fevers. Computed tomography angiography of the chest showed multiple bilateral pulmonary emboli. Transthoracic echocardiogram was remarkable for a mobile mass on the free wall of the right ventricle. The patient improved with therapeutic anticoagulation and a course of steroids. Hypercoagulable workup was unremarkable. Follow-up echocardiogram after 5 months showed complete resolution of right ventricular thrombi. Similarly, Balinski et al ¹⁵ reported a case of central retina vein occlusion diagnosed in a 23-year-old man who had an extensive history of electronic cigarettes use. Partial left-sided vision loss was reported by the patient on presentation. Infectious and autoimmune etiologies were ruled out. Prothrombotic changes in the right middle cerebral artery and elevated right heart pressures were noted. Genetic workup for hereditary thrombosis syndromes, which may trigger hypercoagulability, was unrevealing. The patient was subsequently diagnosed with an electronic cigarette-related clotting episode presenting as CVRO after excluding all other possibilities. Symptoms resolved with anticoagulation.

The use of OCP in young adolescents can trigger hypercoagulable state and thrombosis. It constitutes an independent risk factor for thromboembolism even in women who lack genetic predisposition and other typical risk factors for thrombosis. This is because OCP alters hemostasis through the estrogen component by increasing the plasma levels and activities of coagulation factors while decreasing the inhibitors of coagulation. ¹⁶

The patient under review has left-lower-lobe pulmonary emboli on CTA chest and subacute CVA as shown on the MRI of brain. Before this event, she was on OCP while also indulging in the use of electronic cigarettes. Therefore, it is possible that pulmonary emboli and subacute CVA were triggered by the synergy of events precipitated by both OCP and use of electronic cigarettes. Previous studies have shown higher risk of stroke and venous thromboembolism for women who indulge in tobacco smoking and use OCP alongside. ¹⁷ Because both traditional cigarettes and electronic cigarettes increase platelets aggregation, oxidative stress, and vascular endothelial damage and disrupt endothelial function, ¹⁸ it is possible to see similar outcomes in women combining OCP use with electronic cigarettes. Although this patient was fortunate to have mild symptoms, it is prudent to discourage vaping with electronic cigarettes as a “safe substitute” for traditional cigarettes. In addition, combining OCP use with electronic cigarettes should be outrightly discouraged.

Conclusion

Thromboembolic diseases may have devastating health consequences for young adults. And given the current popularity of electronic cigarettes use, it is imperative for clinicians to aggressively educate young adults on the associated cardiovascular risks. It is equally important to dissuade young females from combining OCP with electronic cigarettes to prevent thromboembolic diseases that may have undesirable effects on their health and well-being.