A CASE OF E-CIGARETTE VAPING-ASSOCIATED INTERSTITIAL LUNG DISEASE WITH CRYPTOGENIC ORGANIZING PNEUMONIA

Abstract

SESSION TITLE: Medical Student/Resident Lung Pathology SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: E-cigarette/Vaping-associated lung injury (EVALI) is a relatively new term that was described in 2019, since then more than 2000 new cases have been reported in USA.(1) Usual cases present with cough/dyspnea associated with hypoxemia and bilateral air-opacities in the Chest X-Ray. (2) Further research is still needed since the histopathologic pattern is not specific and variable. CASE PRESENTATION: We present a case of a 52-year old female with a history of vaping who presented with dyspnea and cough. Patient was tachypneic and hypoxic at 58% on room air. Chest x-ray (CXR) showed bilateral airspace opacities with perihilar and basilar distribution; Chest CT showed diffuse bilateral ground glass opacities (Figure 1). Patient was intubated due to worsening tachypnea and hemodynamic instability on BiPAP; she was started empirically on broad-spectrum antibiotics, and methylprednisolone. She was successfully extubated after 4 days but required re-intubation for persistent respiratory distress. Bronchoalveolar lavage was attempted but due to insufficient sample Video-assisted thoracoscopic surgery with biopsy was performed. Lung biopsy showed cryptogenic organizing pneumonia, (Figure 1) which in this clinical setting suggested a diagnosis of EVALI (Figure 2). Patient was successfully extubated 10 days after the second intubation. She was discharged home with a 6-week course of methylprednisolone. Patient presented to the Emergency department 3-weeks later with acid reflux, and routine CXR was done showing complete resolution of bilateral opacities and no respiratory distress. DISCUSSION: EVALI is a diagnosis of exclusion that usually presents with cough and dyspnea in a patient with a positive screen for vaping-specific history. Chest Imaging can show nonspecific bilateral ground glass opacities or bilateral infiltrates. As per literature review, only 17 patients amongst the thousands with clinical EVALI have an open lung biopsy confirming the presence of acute lung injury with various histopathologic patterns such as acute eosinophilic pneumonia, cryptogenic organizing pneumonia or lipoid pneumonia. (1) Physicians must be able to recognize EVALI as a probable diagnosis, even in community hospitals, since this condition can response to steroids and could be prevented with patient education. CONCLUSIONS: EVALI is becoming a common pathology. This means that physicians in every setting of patient care must be aware of the possibility of EVALI in patients presenting with cough/dyspnea, typical chest imaging and vaping history. Providers should also be familiar with prevention, structured diagnostic approach and treatment of EVALI. (1) Reference #1: Henry TS, et al. Imaging of vaping-associated lung disease; N Engl J Med 2019;381:1486-1487 Reference #2: Hartnett KP, et al. Syndromic Surveillance for E-Cigarette, or Vaping, Product Use–Associated Lung Injury; N Engl J Med. 2019 Dec 20 DISCLOSURES: No relevant relationships by Jorge Cedano, source=Web Response No relevant relationships by Syed Kazmi, source=Web Response No relevant relationships by Anuraag Sah, source=Web Response