A SINGLE ODDITY: EVALI OF THE UNILATERAL LUNG

Abstract

TOPIC: Tobacco Cessation and Prevention TYPE: Medical Student/Resident Case Reports INTRODUCTION: The United States is in an epidemic of electronic cigarette or vaping product use-associated lung injury (EVALI) which is characterized by a combination of respiratory, constitutional and gastrointestinal symptoms1. The most common presenting signs and symptoms include dyspnea, cough, fever, tachypnea, tachycardia, hypoxia, malaise, and emesis2. Two predominant patterns of acute lung injury have been recognized in EVALI: Diffuse Alveolar Damage and Organizing Pneumonia. Radiographic findings in the literature for patients diagnosed with EVALI include a pattern of bilateral and symmetric ground glass opacities with subpleural and areas of lobular sparing3. We present a unique case of severe EVALI isolated to a single lung that has not been documented in the literature and was managed conservatively. CASE PRESENTATION: A 36-year-old male with a history of vaping nicotine products presented with acute onset of dyspnea, hypoxia and tachycardia. Prior to switching to vaping, he admitted to a 7 pack-year smoking history of cigarettes. He endorsed using a Juul© vaping device for two years before switching to another product, Fume©, for 2 months prior to presentation. On physical exam, the patient was tachypneic and in severe respiratory distress with crackles in the right lung. Vital signs were significant for a heart rate of 129 and oxygen saturation of 90% on ambient air. COVID PCR and viral respiratory panel testing were negative. CT of the chest showed diffuse right sided nonspecific reticulonodular pattern with some bronchiectatic changes. Our patient requested conservative management due to financial concerns. Thus we elected to treat without antibiotics and systemic steroids. Supportive treatment included bronchodilators and supplemental oxygen. He improved clinically over the next five days despite our unusual conservative approach. A repeat CT of the chest at that time showed marked interval resolution of radiographic findings. DISCUSSION: Our case highlights that clinicians must be able to recognize that unilateral organizing pneumonia in the setting of recent vaping can be a manifestation of EVALI. Anecdotal literature supports the use of systemic glucocorticoids but an exact treatment of EVALI is not yet known1. The approach in our patient with significant hypoxia and radiographic lung involvement reinforces that supportive treatment of EVALI, as opposed to aggressive measures with empiric antibiotics and systemic glucocorticoids, can lead to similar outcomes without the risk of adverse effects of those medications. CONCLUSIONS: A conservative approach can likely decrease financial burdens for patients and medical institutions and still yield positive medical results. Further longitudinal research is required to determine the benefit of empiric treatment of EVALI and radiographic studies to database future unilateral presentations of EVALI. REFERENCE #1: Werner AK, Koumans EH, Chatham-Stephens K, et al. Hospitalizations and Deaths Associated with EVALI. The New England Journal of Medicine 2020;382;1589-98. REFERENCE #2: Layden JE, Ghinai I, Pray I, et al. Pulmonary illness related to e-cigarette use in Illinois and Wisconsin - preliminary report. N Engl J Med 2019;382:903-916. REFERENCE #3: Kligerman S, Raptis C, Larsen B, et al. Radiologic, Pathologic, Clinical and Physiologic Findings of Electronic Cigarette or Vaping Product Use-associated Lung Injury (EVALI): Evolving Knowledge and Remaining Questions. Radiology 2020;294: 491-505 DISCLOSURES: No relevant relationships by MARIA CANIZARES-OTERO, source=Web Response No relevant relationships by Benjamin Carmel, source=Web Response No relevant relationships by Vijay Srinivasan, source=Web Response No relevant relationships by Hector Vazquez Saad, source=Web Response