A CASE OF ACUTE LUNG INJURY SUPERIMPOSED ON CHRONIC RESPIRATORY BRONCHIOLITIS-INTERSTITIAL LUNG DISEASE

Abstract

SESSION TITLE: Fellows Critical Care Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: The Centers for Disease Control and Prevention have identified 2807 cases of hospitalized patients diagnosed with either “confirmed” or “probable” e cigarette or vaping product use associated lung injury (EVALI)in the United States as of February 18th, 2020. Clinicians should be able to recognize the clinical manifestations and morbidity associated with EVALI. CASE PRESENTATION: A 40 - year old woman with a past medical history of bipolar disorder, type 2 diabetes mellitus,active tobacco abuse, provoked deep venous thrombosis, multiple sclerosis and respiratory bronchiolitis - interstitial lung disease(biopsy proven) presented to the emergency department with progressive dyspnea, pleuritic chest pain and a dry cough. The patient had been vaping for a period of six months using “tetrahydrocannabinol containing products'' and had vaped just prior to admission. Computerized tomography Angiography (CTA) of her chest revealed new extensive bilateral opacities. Her respiratory viral panel polymerase chain reaction was positive for rhinovirus. The patient required endotracheal intubation and mechanical ventilation on account of worsening hypoxia and respiratory distress. Bronchoscopy and bronchoalveolar lavage were performed with her lavage revealing for neutrophil predominance with Oil – Red – O stain seen in greater than 50 percent of macrophages. No fungal or bacterial organisms were grown. The patient was treated with intravenous steroids and antibiotics and extubated 72 hours after intubation. She was discharged home on a steroid taper. A Computerized tomography scan of her chest obtained a month later showed resolution of bilateral infiltrates. While rhinovirus infection may cause acute respiratory distress syndrome (ARDS) in the elderly and immunosuppressed, the presence of so many macrophages demonstrating Oil - Red - O staining point to EVALI as the most likely cause of her acute lung injury superimposed on preexisting respiratory bronchiolitis - interstitial lung disease. DISCUSSION: EVALI is a diagnosis of exclusion as multiple other etiologies of acute lung injury must be excluded. Vitamin E acetate which is used as a diluent in tetrahydrocannabinol vaping products is thought to be a major culprit for the development of acute lung injury. Common presenting features are coughing, dyspnea and chest pain with fevers, chills and weight loss. Radiographic findings include bilateral pulmonary infiltrates and opacities on chest X ray and chest computerized tomography scans. Bronchoscopy and bronchoalveolar lavage to rule out alternative diagnoses may be useful. There is no specific treatment, however corticosteroids and empiric antibiotics may be considered. CONCLUSIONS: It is important to have a high clinical suspicion for EVALI in patients who vape and present with respiratory failure and similar complaints and encourage attempts at E- cigarette/vaping cessation. Reference #1: Cao DJ, Aldy K, Hsu S, McGetrick M, Verbeck G, De Silva I, et al. Review of Health Consequences of Electronic Cigarettes and the Outbreak of Electronic Cigarette, or Vaping, Product Use-Associated Lung Injury. J Med Toxicol. 2020. Reference #2: Longtin J, Winter AL, Heng D, Marchand-Austin A, Eshaghi A, Patel S, et al. Severe human rhinovirus outbreak associated with fatalities in a long-term care facility in Ontario, Canada. J Am Geriatr Soc. 2010;58(10):2036-8. Reference #3: Siegel DA, Jatlaoui TC, Koumans EH, Kiernan EA, Layer M, Cates JE, et al. Update: Interim Guidance for Health Care Providers Evaluating and Caring for Patients with Suspected E-cigarette, or Vaping, Product Use Associated Lung Injury - United States, October 2019. MMWR Morb Mortal Wkly Rep. 2019;68(41):919-27. DISCLOSURES: No relevant relationships by Kwesi Amoah, source=Web Response No relevant relationships by Michael Buscher, source=Web Response No relevant relationships by Kulothungan Gunasekaran, source=Web Response No relevant relationships by Mandeep Singh Rahi, source=Web Response