AN UNUSUAL CASE OF CARDIOVASCULAR COLLAPSE AFTER EVALI

Abstract

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: In July of 2019, a new respiratory illness emerged as a cluster of healthy, young adolescents developed profound hypoxic respiratory failure. Investigation revealed that it was related to e-cigarette and vaping use. A new clinical syndrome of e-cigarette and vaping use-associated lung injury (EVALI) emerged. Its development was linked to tetrahydrocannabinol use and Vitamin E acetate. We present a case of vaping associated lung injury, resulting in severe acute respiratory distress syndrome with eventual, unexplained cardiovascular collapse and death. CASE PRESENTATION: Patient is a 37 year-old male with migraines, obesity, chronic back pain, and tetrahydrocannabinol vaping who presented with fever, shortness of breath, and altered mental status. His symptoms started with a fever 3 days prior to arrival. He arrived in distress. He was febrile, tachycardic, tachypneic, and profoundly hypoxic to 54% on room air. His blood pressure was 113/59. Initial blood gas confirmed profound hypoxemia with pH 7.33, PCO2 35.5, PO2 32.9, and saturation of 63.8 with a lactate of 8.6 mmol/L. Initial chest x-ray showed bilateral infiltrates. Patient was intubated and admitted to ICU. His initial PaO2 to FI02 ratio was 111 on a PEEP of 12, consistent with moderate ARDS. Infectious work-up including viral PCR, respiratory and blood cultures were negative. Bronchoscopy showed diffuse, pink frothy secretions in the upper airways with bronchoalveolar lavage growing commensal flora. Echocardiogram showed preserved EF and CT chest negative for pulmonary embolism, but demonstrated extensive, bilateral ground glass and airspace opacities. He completed a 14 day course of both steroids and antibiotics and gradually improved with diuresis. After initial extubation, he again decompensated and was re-intubated. He developed new EKG changes with ST elevations, reciprocal depressions, and a significant troponin elevation. Patient suffered PEA arrest and cardiac catheterization was emergently performed which demonstrated non-obstructed coronary arteries and patent pulmonary vasculature. Patient was initiated on VA ECMO. Patient further decompensated developing multi-organ failure despite VA ECMO support. Due to his poor prognosis, the decision was ultimately made to withdraw care. DISCUSSION: This patient fulfills diagnostic criteria for EVALI, including e-cigarette use within the last 90 days, lung opacities on chest radiograph or CT, exclusion of lung infection, and absence of alternative diagnosis. This case report highlights an instance of acute cardiovascular collapse in a patient with EVALI after initial course of improvement and extended treatment with antibiotics and steroids. CONCLUSIONS: Patients recovering from EVALI can experience rapid deterioration and should undergo close monitoring in an ICU setting. Physicians should also maintain a low threshold to resume treatment in the appropriate clinical setting. Reference #1: Pray IWP, Atti SKM, Tomasallo CP, Meiman JGM. E-cigarette, or Vaping, Product Use–Associated Lung Injury Among Clusters of Patients Reporting Shared Product Use — Wisconsin, 2019. In. Vol 69. Morbidity and Mortality Weekly Report 2020:236-240. Reference #2: Messina MD, Levin TL, Conrad LA, Bidiwala A. Vaping associated lung injury: A potentially life-threatening epidemic in US youth. Pediatr Pulmonol. 2020. Reference #3: Layden JE, Ghinai I, Pray I, et al. Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin - Final Report. N Engl J Med. 2020;382(10):903-916. DISCLOSURES: No relevant relationships by Zachary Bauer, source=Web Response No relevant relationships by Sophia Binz-Johnson, source=Web Response No relevant relationships by Aeman Hana, source=Web Response No relevant relationships by Christopher Kassab, source=Web Response No relevant relationships by Harish Kinni, source=Web Response No relevant relationships by Jennifer Swiderek, source=Web Response