Case Report

Progression of Buerger’s Disease in the Absence of Conventional Tobacco

Exposure: A Case of Vape Associated Disease
Nashwah Memon1,3, Omar Alani2, S Minhaj Rahman3, Fahad Ahmed4, Adel Haque5,6*
1Lake
Erie College of Osteopathic Medicine, Bradenton, Florida, USA
2Icahn
School of Medicine at Mount Sinai, New York, New York, USA
3Department of Medicine, Northwell Health Northern Westchester Hospital, Mount Kisco, New York, USA

4Department of Dermatology, University of Miami Health System, Miami, Florida, USA

5Dermatology Partners, Macungie, Pennsylvania, USA

6Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA

*Correspondence author: Adel Haque, MD, Adjunct Assistant Professor of Dermatology, Department of Dermatology, University of Pennsylvania,
Philadelphia, Pennsylvania, USA; Email: [email protected]

Abstract
Citation: Memon N, et al.
Thromboangiitis Obliterans (TAO), or Buerger’s disease, is a nonatherosclerotic, inflammatory
Progression of Buerger’s Disease in
vasculopathy primarily affecting small and medium-sized vessels, most often in the distal
the Absence of Conventional
Tobacco Exposure: A Case of Vape
extremities and is strongly associated with tobacco use. We present the case of a 29-year-old male
Associated Disease. J Dermatol with minimal prior cigarette smoking history who developed clinically apparent Buerger’s disease
Res. 2025;6(2):1-3. only following exclusive and heavy use of e-cigarette vaping. While cigarette, tobacco smoke is a
https://doi.org/10.46889/JDR.2025. well-established trigger, it is unclear what role nicotine or e-cigarette vape antigens may play in
6205 the role of Buerger’s disease. This case supports growing evidence that nicotine delivery systems,
including e-cigarettes, may contribute to the pathogenesis or progression of Buerger’s disease.
Received Date: 23-04-2025 Clinicians should be aware of vaping as a potential risk factor and counsel patients with Buerger’s
Accepted Date: 19-05-2025 disease on the importance of complete smoking cessation, regardless of delivery method.
Published Date: 26-05-2025
Keywords: Thromboangiitis Obliterans; Tobacco; Buerger’s Disease; Smoking

Introduction
Copyright: © 2025 by the authors. Thromboangiitis Obliterans (TAO), also known as Buerger’s Disease, is characterized as a
Submitted for possible open access nonatherosclerotic, inflammatory vascular disease with a predisposition for small and medium-
publication under the terms and sized arteries and veins classically of the distal extremities. Although the condition is associated
conditions of the Creative with inflammatory intraluminal occlusion with sparing of the vessel wall, the pathogenesis of
Commons Attribution (CCBY)
these findings is not well understood. Tobacco smoking is highly associated with the development
license
of Buerger’s disease with some suggesting a toxic inflammatory pathogenesis of disease. In
(https://creativecommons.org/li
censes/by/4.0/).
multiple previous studies, smoking cessation and discontinuation of tobacco products
demonstrate significant regression in symptoms and are significantly associated with improved
outcomes with interventional procedures [1,2]. We present the case of a patient with minimal
tobacco cigarette exposure who only developed clinically evident Buerger’s disease after cigarette cessation while heavily
utilizing e-cigarette vape products.

Case Report
A 29-year-old male with no significant atherosclerotic or hypercoagulable medical history was referred to our clinic for the
evaluation of painful left hand first, second and third digit in July 2023 (Fig. 1). The patient reported a history of conventional
tobacco cigarette smoking of 1-3 cigarettes daily (<1/4th pack per day) for approximately 10 years, but with complete cigarette
and tobacco cessation for the previous 10 months (since September 2022). He reported initiation and heavy e-cigarette vape use
three months prior to presentation, consistently using a 50-mg nicotine pod (BC5000 vape cartridges, assorted flavors,
manufactured by EBCREATE) weekly. He denied use of any other tobacco producing including chewing tobacco.

https://doi.org/10.46889/JDR.2025.6205 https://athenaeumpub.com/journal-of-dermatology-research/
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Figure 1: Clinical image of patient’s left first through fourth digits on presentation in July 2023.

Prior to approximately November 2022, the patient denied any past medical history of superficial thrombophlebitis, cold
sensitivity or Raynaud’s phenomenon, digital or organ ischemia, or any joint complaints. From November 2022 onwards until
presentation in July 2023, the patient reports he began to experience cold sensitivity and pain of his bilateral distal hands, worst
in the left hand. In the weeks leading to presentation, he began to have progression of pain in his left hand 1st-3rd digits with
discoloration and ultimately development of ulcerations, unresponsive to NSAIDs. On physical exam in clinic, the patient was
noted to have 2+ peripheral pulses to the bilateral posterior tibial and dorsalis pedis pulses, reduced 1 + left radial pulse and 2+ on
the right radial pulse. His left hand demonstrated ischemic changes with mottled skin changes, nail clubbing and ulcerations of
the left 1st, 2nd and 3rd distal digits. Arterial duplex ultrasonography demonstrated a moderate-severe reduction in perfusion to
the distal left upper extremity vessels. Autoimmune markers including ANA, RF and ANCA antibodies were negative.

He was counseled on complete smoking cessation (including the use of e-cigarettes) and was prescribed nifedipine extended-
release 30 mg daily and nicotine replacement therapy. Within two weeks of his visit, he successfully eliminated his e-cigarette
use and reported markedly improved pain, healing wounds and decreased cold sensitivity of his distal hands. Follow-up at 6
months and 1 year demonstrated continued improvement of symptoms and no further distal extremity ulceration, pain, or
Raynaud’s with continued smoking abstinence.

Discussion
In this case, we present a unique case of e-cigarette induced progression of Buerger’s disease. Although our patient endorsed a
mild approximately 3 pack-year history of tobacco cigarette smoking, he only developed clinical symptoms and progression of
disease with heavy e-cigarette vaping exposure. While the pathogenesis of Buerger’s disease, or thromboangiitis obliterans, is
not well understood, there are clear links between tobacoo smoking and its development. It is hypothesized that tobacco smoking
induces a localized inflammatory reaction to endothelial injury in small and medium sized arteries and veins. Multiple
immunohistochemical analyses have identified cellular infiltrates and increased production of cytokines in the development of
this disease suggesting an immune mediated vasculitis [3,4]. While certain tobacco-specific antigens have been implicated in the
pathogenesis of Buerger’s disease, it is unclear how other antigens found in nicotine and vape-cartridges alone without nicotine
contribute to the development of Buerger’s. Nicotine is known to induce vasoconstriction, endothelial dysfunction and promotes
a pro-thrombotic state by increasing platelet aggregation and impairing nitric oxide-mediated vasodilation [5]. Additionally, it
may contribute to immune dysregulation by activating inflammatory pathways in genetically susceptible individuals. These
mechanisms can lead to segmental inflammation and thrombosis of small and medium-sized vessels, characteristic of
thromboangiitis obliterans. Interestingly, our patient reported dramatic improvement in symptoms with vaping cessation-
consistent with results seen in those who implement tobacco smoking cessation. Previous reports have suggested the
development and/or progression of Buerger’s without conventional tobacco smoking. For instance, Lawrence, et al., reported
progression of disease requiring limb amputation in a patient who had substituted tobacco cigarette smoking with smokeless
chewing tobacco, also suggesting that complete abstinence for all use of tobacco was advisable [6]. There are also rare case reports

https://doi.org/10.46889/JDR.2025.6205 https://athenaeumpub.com/journal-of-dermatology-research/
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of Buerger’s disease in patients without tobacco exposure, suggesting possible other causes of endothelial damage including
cannabis or autoimmune induced [7,8]. To our knowledge, there are no previous reports of vape-associated development or
progression of Buerger’s Disease reported in the literature. Our patient’s development, progression and resolution of symptoms
associated with Buerger’s disease parallel those that have been observed in tobacco-associated disease, suggesting potentially
similar pathogenesis. Our report provides a case of evidence between the association of e-cigarette vape use and the progression
of Buerger’s disease and supports previous literature regarding the effects of nicotine on vascular disease. This report highlights
that clinicians should be aware of this potential association and counsel Buerger’s disease patients on complete smoking
cessation, including the use of e-cigarettes, as patient’s may progress in their clinical disease with vaping alone.

Conclusion
This case highlights the potential for e-cigarette use to induce or exacerbate Buerger’s disease, even in the absence of significant
traditional tobacco exposure. Clinicians should recognize vaping as a possible risk factor and counsel patients on the importance
of complete nicotine cessation-including e-cigarettes to prevent disease progression and optimize vascular outcomes.

Conflicts of Interest
The authors declare no conflict of interest in this paper.

Funding
None

Patient Consent
Informed consent was obtained from the patient for publication of this case report and any accompanying images.

Ethical Approval
This case study was determined to be institutional review board exempt from further review.

References
1. Mills JL, Porter JM. Buerger's disease (thromboangiitis obliterans). Ann Vasc Surg. 1991;5(6):570-2.
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for thromboangiitis obliterans. J Vasc Interv Radiol. 2023;34(6):1038-44.
3. Papa M, Bass A, Adar R, Halperin Z, Schneiderman J, Becker CG, et al. Autoimmune mechanisms in thromboangiitis obliterans (Buerger's
disease): the role of tobacco antigen and the major histocompatibility complex. Surgery. 1992;111(5):527-31.
4. Lee T, Seo JW, Sumpio BE, Kim SJ. Immunobiologic analysis of arterial tissue in Buerger's disease. Eur J Vasc Endovasc Surg.
2003;25(5):451-7.
5. Whitehead AK, Erwin AP, Yue X. Nicotine and vascular dysfunction. Acta Physiol (Oxf). 2021;231(4):e13631.
6. Lawrence PF, Lund OI, Jimenez JC, Muttalib R. Substitution of smokeless tobacco for cigarettes in Buerger's disease does not prevent limb
loss. J Vasc Surg. 2008;48(1):210-2.
7. Shima N, Akiyama Y, Yamamoto S. A non-smoking woman with anti-phospholipid antibodies proved to have thromboangiitis obliterans.
Intern Med. 2020;59(3):439-43.
8. Banana Y, Bashir H, Boukabous S, Rezziki A, Benzirar A, El Mahi O. Cannabis arteritis: A case report and brief review of the literature.
Ann Med Surg (Lond). 2022;76:103523.

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