EVALI Presenting as Diffuse Alveolar Hemorrhage in an Adolescent. Case Report

To the Editor,

We report the case of a 14‐year‐old boy who presented to the emergency department with dyspnea. He was an active smoker (three cigarettes per day) and user of electronic cigarettes. He reported a 2‐day history of malaise and increased cough with whitish sputum, accompanied by fever up to 38°C. After 24 h, he developed blood‐streaked sputum progressing to frank hemoptysis. On examination, his temperature was 37.8°C, heart rate 139 beats/min, respiratory rate 34 breaths/min with use of accessory muscles, and oxygen saturation (SpO₂) 85% on room air. Low‐flow oxygen therapy was initiated. Pulmonary auscultation revealed bilateral crackles, more pronounced on the right hemithorax. Laboratory tests showed elevated inflammatory markers (C‐reactive protein 9.3 mg/dL, fibrinogen 746 mg/dL), leukocytosis (16,800/µL), and anemia (hemoglobin 10.7 g/dL), without coagulopathy. Arterial blood gas analysis showed acute partial respiratory failure (PaO₂ 37 mmHg). Chest radiography demonstrated bilateral alveolo‐interstitial infiltrates (Figure 1). Thoracic aortic CT angiography revealed multiple bilateral lobular parenchymal opacities with a tendency toward consolidation and a predominantly perihilar distribution, sparing the subpleural regions. Opacities were more extensive in the right lung and involved the middle and lower zones of the left lung, consistent with acute diffuse alveolar hemorrhage (DAH) (Figure 2).

Figure 1.

Posteroanterior chest radiograph obtained at Emergency Department in which we can see extensive and asymmetric bilateral alveolar opacities, predominantly in the right lung. These opacities have a perihilar and mid‐to‐lower lung distribution.

Figure 2.

Axial contrast thoracic aortic CT Angiography obtained at Emergency Department in which we can see an extensive and asymmetric bilateral ground‐glass and consolidative opacities, markedly more pronounced in the right lung, with predominant involvement of the dependent lower lobes. In the appropriate clinical context of acute hemoptysis and anemia, these findings were consistent with diffuse alveolar hemorrhage.

Given the clinical presentation and findings, the patient was admitted to the pediatric intensive care unit (PICU) for close monitoring and potential respiratory or hemodynamic support. Empirical intravenous antibiotic therapy with amoxicillin/clavulanate and azithromycin was initiated because concurrent respiratory infection could not be excluded. Intravenous tranexamic acid (500 mg every 8 h) and oral dextromethorphan were also administered to prevent further hemoptysis episodes.

Within 24 h of PICU admission, flexible bronchoscopy (2.8 mm videobronchoscope) under non‐invasive ventilation showed no anatomical abnormalities. Bronchoalveolar lavage (BAL) was obtained from the middle lobe, with instillation of 100 mL and recovery of 38 mL of progressively bloodier fluid in sequential aliquots. BAL cytology revealed a predominance of polymorphonuclear cells (macrophages 50%, neutrophils 47%, lymphocytes 2%, eosinophils 1%). Microbiological studies, including viral, bacterial, fungal, and mycobacterial testing, were negative except for rhinovirus PCR (1056 copies/mL). Cytological examination showed hemosiderin‐laden macrophages (Figure 3) and lipid‐laden macrophages identified with Oil Red O staining (Figure 4). Autoimmune screening (antinuclear antibodies, anti–double‐stranded DNA, antineutrophil cytoplasmic antibodies, anti‐MPO, anti‐PR3, and anti‐GBM) and serology for hepatotropic viruses were negative.

Figure 3.

Cytological smear of bronchoalveolar lavage fluid stained with Papanicolaou showing a hemorrhagic background with numerous macrophages, some of which contain hemosiderin within their cytoplasm, appearing as brownish pigment granules. [Color figure can be viewed at wileyonlinelibrary.com]

Figure 4.

Bronchoalveolar lavage cytology (×40 magnification) showing abundant macrophages in a hemorrhagic background. Oil Red staining, which highlights neutral lipids, triglycerides, and fatty acids, demonstrates numerous lipid‐laden macrophages. [Color figure can be viewed at wileyonlinelibrary.com]

Given these findings and the patient's habitual use of electronic cigarettes, DAH was considered most likely secondary to E‐cigarette or Vaping product use–Associated Lung Injury (EVALI). Intravenous methylprednisolone (1 mg/kg/day) was initiated, followed by marked clinical improvement with reduced dyspnea, work of breathing, and oxygen requirements. Hemoptysis progressively resolved, and follow‐up imaging demonstrated complete resolution of the bilateral infiltrates. The patient was discharged from the PICU on Day 5.

Alveolar hemorrhage is an uncommon manifestation of EVALI and may occur in individuals without preexisting pulmonary disease [1]. Its nonspecific presentation may mimic infection and can be severe, with reported cases requiring ICU admission and extracorporeal membrane oxygenation (ECMO) [2]. Although particularly uncommon in pediatric patients, EVALI‐associated DAH should be considered in adolescents who use e‐cigarettes or vaping devices. The presence of lipid‐laden macrophages are not considered a characteristic finding of diffuse alveolar hemorrhage, which is typically characterized by progressively hemorrhagic BAL aliquots and, subsequently, hemosiderin‐laden macrophages [3]. Although lipid‐laden macrophages have been reported in EVALI, they are nonspecific and should not be considered diagnostic in isolation. Nevertheless, their presence may provide supportive evidence when interpreted in the context of a compatible clinical presentation and documented vaping exposure [4, 5]

Author Contributions

Sergio Domingos Hompanera: conceptualization, investigation, funding acquisition, writing – original draft, methodology, validation, visualization, writing – review and editing, software, formal analysis, project administration, resources, data curation. Pablo Lozano Cuesta: supervision, resources, data curation, software, formal analysis, project administration, writing – review and editing, visualization, validation, methodology, conceptualization, investigation, funding acquisition, writing – original draft. Liliana Pérez Martínez: conceptualization, investigation, funding acquisition, methodology, validation, visualization, software, formal analysis, resources, supervision, data curation, project administration, writing – original draft, writing – review and editing.

Funding

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Declaration of Generative AI and AI‐Assisted Thecnologies in the Manuscript Preparation Process

During the preparation of this work, the author(s) used ChatGPT for the purpose of improving language and readability. After using this tool/service, the author(s) reviewed and edited the content as necessary and take full responsibility for the content of the publication

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.