TOPIC: Critical Care
TYPE: Medical Student/Resident Case Reports
INTRODUCTION: Electronic Vaping Acute Lung Injury (EVALI) is a novel disease that emerged amongst young adults in 2019. There was an abundance of focus on EVALI until the pandemic. CDC reported incidence for EVALI was ~ 2,807 hospitalizations as of February 2020. Although the pathophysiology is not fully understood, it is hypothesized that inhaled/vaporized oils interact with surfactant and phospholipids, damaging the alveolar epithelial lining. This case masqueraded as the prototypical COVID-19 presentation during the peak of the pandemic in South Florida, yet, after 3 negative COVID PCR, the primary differential became Hypersensitivity Pneumonitis secondary to electronic vaping.
CASE PRESENTATION: A 27-year-old Caucasian male with a history of anxiety presented with fever, nausea, vomiting, diarrhea, and worsening shortness of breath for five days. He admitted to not following social distancing guidelines and heavy alcohol use the night before symptoms began. After two days of worsening symptoms and a negative COVID test he went to the ER. He admitted use of electronic vape to smoke 3-4 cartridges of marijuana per week. He was profusely diaphoretic, tachycardic, tachypneic and hypoxic. CRP 39 mg/dL, D-dimer 0.73 ug/mL, WBC 15 x10^3/uL and lymphopenia. Imaging of the chest showed diffuse patchy ground-glass opacities bilaterally (Fig 1, 2). This constellation of labs, imaging and lack of social distancing screamed COVID-19, however he had three negative COVID PCRs.The patient rapidly declined becoming progressively more hypoxemic ultimately requiring intubation. Throughout the admission treatment included high-dose corticosteroids and later, broad spectrum antibiotics due to HAP. Complications included several pneumothoraces and a large pneumatocele (Fig 3) requiring CT-guided drainage. After 2 months in the ICU he finally stabilized and began his slow recovery. He was able to be discharged, with trach collar, to a rehab facility after greater than 3 months in the hospital.
DISCUSSION: With increasing use of electronic vaping, it is imperative that clinicians be able to expediently diagnose EVALI in order to prevent and prepare for impending sequelae. After a thorough history and exclusion of alternatives, such as infectious or rheumatologic causes, EVALI should be closely monitored as these patients can deteriorate quickly with severe hypoxemia, ARDS, and in our case multiple pneumothoraces and pneumatoceles. Early high dose corticosteroid administration and prevention of barotrauma during mechanical ventilation can potentially reduce complications.
CONCLUSIONS: This case report aims to increase awareness of EVALI amid the COVID-19 pandemic. Early identification and intervention of EVALI may prevent catastrophic lung damage, as seen in our patient. Health care providers must educate patients on the importance of cessation of vape products.
REFERENCE #1: Centers for Disease Control and Prevention. (2020, November 27). Outbreak of Lung Injury Associated with the Use of E-Cigarette, or Vaping, Products. Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html.
REFERENCE #2: Chand, H. S., Muthumalage, T., Maziak, W., & Rahman, I. (2020). Pulmonary Toxicity and the Pathophysiology of Electronic Cigarette, or Vaping Product, Use Associated Lung Injury. Frontiers in Pharmacology, 10. https://doi.org/10.3389/fphar.2019.01619
REFERENCE #3: Christiani, D. C. (2020). Vaping-Induced Acute Lung Injury. New England Journal of Medicine, 382(10), 960–962. https://doi.org/10.1056/nejme1912032
DISCLOSURES: No relevant relationships by Jehon Amen, source=Web Response
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