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(CNN) - U.S. Health Officials They announced on Friday that they now know at least 450 possible cases of serious lung disease that could be caused by vaping. These cases, which have occurred in 33 states and one jurisdiction, include some cases that are still under investigation by state health officials.
Officials of the Centers for Disease Control and Prevention. (CDC) on Friday revealed a third confirmed death in Indiana. Two deaths, one in Illinois and one in Oregon, had been previously reported. A fourth death is still under investigation, CDC officials said, but did not identify the state where it occurred.
Also on Friday, two other health departments announced similar deaths.
Minnesota health officials announced the death in their state of someone over 65, who had a history of underlying lung disease and died in August. The Minnesota patient had a "long and complicated hospitalization" that involved "a serious lung injury that progressed to include other conditions," according to the statement. After the patient died, the researchers linked the lung injury with "vaping illicit THC products."
READ : Report another death from lung disease linked to vaping in the United States
Another possible death related to vaping was also reported in Los Angeles County, according to an announcement from the Los Angeles County Department of Public Health.
CNN contacted the CDC to confirm whether the Minnesota or California cases were the fourth death under investigation.
"People should consider not using electronic cigarettes"
The CDC, the Food and Drug Administration (FDA) and state health departments say they are working together to determine what products could have been used and to facilitate laboratory testing. Health officials say they have not found a definitive cause or a clear connection between cases, but some are focusing on possible leads.
LEE : State health officials investigate the link between vaping and severe lung disease
"We believe that a chemical exposure is probably associated with these diseases," Dr. Dana Meaney-Delman, incident manager at the CDC for the response to the outbreak, told reporters on Friday.
“At this time, no device, product or substance has been related to all cases,” he added, “and ongoing research is needed to better understand if there is a true relationship between any specific product or substance and the diseases we are observing in the patients".
The CDC and several state health departments have reported the widespread use of products containing THC or tetrahydrocannabinol, the psychoactive substance in cannabis.
On Thursday, New York health officials said their research had found "very high levels" of vitamin E chemical acetate in almost all the vaping products that contained cannabis that were tested. The chemist is now "a key focus" of the department's research on diseases.
Mitch Zeller, director of the FDA's Tobacco Products Center, told reporters that "no substance or compound, including vitamin E acetate, has been identified in all samples tested." So far, the agency has received more than 120 samples that present a "combination of results," he said.
"It is important to emphasize that identifying any compound that is present in the samples will eventually prove to be a puzzle piece that will not necessarily answer questions about causation," said Zeller, who encouraged anyone who had an unexpected health problem or with products of Vaping notify the FDA through its online security reporting portal.
Doctors also think that it is possible that mixing a variety of ingredients in vapors may lead to the creation of new toxic agents.
Meaney-Delman warned users on Friday not to buy electronic cigarette products from the street or modify them in any way. He added that the main way to prevent these diseases is not to vape at all.
"The most important thing, while this research is ongoing, is that people should consider not using electronic cigarette products," he said.
New reports emerge
In a preliminary report published Friday in the New England Journal of Medicine , Illinois and Wisconsin health officials gave a breakdown of the first 53 cases in their states: 83% were men, with an average age of 19, and 94% had been hospitalized. More than half landed in the intensive care unit, and about a third needed intubation and mechanical support to breathe.
Although the patients are "generally young and healthy", almost all experienced respiratory symptoms such as difficulty breathing, 81% had gastrointestinal symptoms and all had general symptoms such as fever, fatigue or weight loss.
READ : The FDA warns companies to stop marketing illegally vaping products
The vast majority - 84% - had used products containing THC, although "a wide variety of products and devices were reported," the authors said.
In another report published in the same journal, doctors said they found different imaging patterns in lung scanners, which might suggest "different mechanisms of injury."
One of these patterns was lipoid pneumonia, which was the focus of another report published Friday on the "outbreak" in North Carolina.
"It can happen when oils or substances that contain lipids enter the lungs," said one of the authors of that report, Dr. Daniel Fox, a pulmonary and critical care physician at WakeMed Health and Hospitals in North Carolina. "It's a rare diagnosis."
According to his report, a possible explanation for why five patients developed lipoid pneumonia was that aerosol oils were deposited in their airways, causing local inflammation that impaired their lung function. Case reports from previous years have also linked vaping with lipoid pneumonia.
Meaney-Delman warned that it is unclear whether these lipids came from electronic cigarettes, somewhere inside the body or from some other source. "It is too early to know" if such findings, also described by doctors at the University of Utah Health University on Friday, will provide a key clue to the investigation, he said.
Experts say the prevalence of lung disease potentially attributable to vaping could be much higher, since doctors may not detect some of the milder cases.
"These cases may be some of the most serious and the full spectrum of the disease may be broader," he said.
Jacqueline Howard and Jamie Gumbrecht of CNN contributed to this report.