Large Emphysematous Bulla After IQOS Use: A Case-Based Literature Review

Background and Clinical Significance: Heated tobacco products (HTPs) are a re-emerging class of tobacco products that present themselves as alternatives to conventional cigarettes with reduced risks. However, recent evidence has shown potential association with lung injury. We present a case of a pulmonary complication associated with use of IQOS, a popular HTP, contributing to the growing evidence of its risks. Case Presentation: A 22-year-old man presented with sharp right posterior thoracic pain, antalgic dyspnea, chills which developed suddenly in the morning, and fever. He had no past medical history. He had been a conventional smoker for 2 years (1 pack-year) but had switched to IQOS for the previous 4 years. A thoracic X-ray examination showed a big emphysematous bulla, about 84/60 mm, located in the right middle pulmonary lobe. A thoracic CT scan described a cyst of 77/84/62 mm with hydroaeric level in the right lobe and another emphysema bulla of 11 mm in the inferior right lobe. A differential diagnosis was performed, and autoimmune diseases, tuberculosis and viral infections were excluded. Alpha-1 antitrypsin level was normal. Blood culture was positive for Pseudomonas aeruginosa. After 4 weeks of antibiotic therapy, the infection was cured. Surgery was necessary for pleuro-pulmonary release with division of adhesions of the giant bulla. Conclusions: Case reports of pulmonary injury associated with IQOS use need to be published, contributing to a better understanding of the product's toxicity and health impact.