Researchers still don’t know exactly how bad vaping is for your health, but the results of one case study might make you think before you spark up that e-cigarette.

The case study, published in the European Respiratory Journal, focused on one patient (a 49-year-old “previously healthy” white woman from California), who was diagnosed with a rare lung disease known as "cobalt lung" after presenting with a cough, wheezing, and shortness of breath when exercising.

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Researchers at the University of California San Francisco reported that the patient had a lung disease medically known as giant cell interstitial pneumonia (also called hard metal pneumoconiosis or hard metal lung disease, in addition to cobalt lung).

The illness is normally found in industrial workers who have been exposed to metals like cobalt or tungsten, commonly used in metal mining, smelting, and refining, and in the manufacture or use of cutting or grinding tools. But the woman’s doctors believe her case could be the first linked to vaping.

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There’s been no shortage of reported vaping illnesses across the US, with people displaying the same symptoms: coughing, wheezing, and shortness of breath. However, when doctors examined the woman’s lung tissue, the damage looked different than damage caused by typical vaping injuries. Under the microscope, they observed impaired cells that had consumed other cells, forming giant cells––the same pattern typically found in hard metal lung disease.

When the docs tested the woman’s e-cigarette, a ZenPen brand vape pen she’d been using with marijuana for six months before getting ill, they found cobalt in its vapor, plus other nasty toxins like aluminum, chromium, lead, manganese, and nickel.

The study authors hypothesize that the metals found in the e-liquid leached from the heating coil in the vape pen. The fact that the woman was vaping marijuana is significant, because it raises the risk of leaching––the pen must be heated to a much higher temperature to aerosolize THC than to aerosolize nicotine. The higher temperature releases a greater amount of toxic substances, per research published in the journal Environmental Science & Technology in 2016.

The authors of the new case study stated that their findings prove vaping devices must be regulated. “The public health implications of this are substantial given the increasing trend towards legalization of cannabis for recreational and medical purposes,” they wrote.

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Although the woman’s lung damage is probably permanent, her doctors said her lung function may improve. Lung injuries from vaping devices have been reported in all 50 states, with Alaska reporting its first case on Tuesday. The Centers for Disease Control and Prevention previously said 2,290 lung injury cases were reported from 49 states, two US territories, and the District of Columbia, with 47 vaping deaths confirmed in 25 states and the District of Columbia.

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