A CASE OF VAPING-RELATED LUNG INJURY MIMICKING COVID-19

Abstract

TOPIC: Tobacco Cessation and Prevention TYPE: Medical Student/Resident Case Reports INTRODUCTION: E-cigarette and vaping associated lung injury (EVALI) was first recognized in 2019 and can present with acute onset respiratory distress mimicking that of COVID-19. It is important to consider in a young patient with a significant vaping history. CASE PRESENTATION: A 19-year-old male with a history of anxiety, depression, and delusional disorder presented with worsening dyspnea, fever and productive cough, nausea, vomiting, diarrhea for 1 week. He had gone to urgent care where he had tested negative for COVID19 twice and was started on Azithromycin. He denied any exposure to COVID positive individuals but reported that his siblings' school had a recent outbreak. Vitals on admission were temperature 100.3F, Heart rate 121, Respiratory rate 24, Blood Pressure 157/97, pulse oximetry 81% on Room Air, improved after 6L supplemental oxygen. Labs significant for leukocytosis of 19.4K, normal procalcitonin, ESR >130, ferritin 443, LDH 694, CRP 358. Urine drug screen positive for THC (tetrahydrocannabinol). Urine was negative for Legionella and Strep pneumoniae. COVID testing were negative on 3 separate occasions. Chest x-ray showed mild-moderate pulmonary congestion, but no effusions. Chest CTA showed patchy parenchymal interstitial infiltrates bilaterally, suspicious for nonspecific pneumonitis/atypical viral pneumonia or pulmonary edema, but no pulmonary embolus. Blood cultures and sputum cultures negative.On further questioning, he attested to vaping and smoking marijuana through a bong; he had recently bought a new THC product off the street for vaping that contained vitamin E acetate. Given his history of vaping and his failed treatment with antibiotics, we considered EVALI. He was started on prednisone 40mg daily and 5 day course of Azithromycin and Ceftriaxone. On the 4th day of hospitalization, he showed significant clinical improvement and was no longer requiring oxygen supplementation. The patient was discharged on Day 5. Repeat chest xray 5 days after discharge showed no evidence of active disease. DISCUSSION: EVALI is a diagnosis of exclusion; it can mimic atypical and viral pneumonias, most notably COVID-19. Vitamin E acetate is the main causative agent, resulting in an acute lung injury with findings of acute fibrinous pneumonitis, diffuse alveolar damage, or organizing pneumonia. Patients are usually treated with supportive care, antibiotics, and systemic steroids. The COVID19 pandemic poses a diagnostic challenge to accurately diagnose cases of EVALI due to the similar presentation of both diseases: acute to subacute respiratory symptoms with gastrointestinal symptoms, ground-glass opacities on CT, and elevated inflammatory markers. CONCLUSIONS: Similar to COVID19, EVALI can also be fatal, and should not be overlooked as a diagnosis. A thorough history is imperative in reaching a diagnosis, and can save PPE use, and decrease hospitalization cost. REFERENCE #1: "Outbreak of Lung Injury Associated with the Use of E-Cigarette, or Vaping, Products." Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 27 Nov. 2020, www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html#overview. REFERENCE #2: Blount, Benjamin C., et al. "Vitamin E Acetate in Bronchoalveolar-Lavage Fluid Associated with EVALI." New England Journal of Medicine, vol. 382, no. 8, 2020, pp. 697–705., doi:10.1056/nejmoa1916433. REFERENCE #3: Hollingsworth, Helen. UpToDate, 9 Feb. 2021, www.uptodate.com/contents/e-cigarette-or-vaping-product-use-associated-lung-injury-evali?search=evali&source=search_result&selectedTitle=1~13&usage_type=default&display_rank=1#H4113759245. DISCLOSURES: No relevant relationships by Rebecca Greenspan, source=Web Response No relevant relationships by Areej Khan, source=Web Response No relevant relationships by Manpreet Mann, source=Web Response No relevant relationships by Krishnaveni Sirigaddi, source=Web Response