M409 ELECTRONIC CIGARETTE OR VAPING PRODUCT USE-ASSOCIATED LUNG INJURY AMIDST THE COVID-19 PANDEMIC

Abstract

Electronic cigarette or vaping product use-associated lung injury (EVALI) is currently a diagnosis of exclusion. Given the pro-inflammatory and partly immune-mediated pathogenesis, EVALI and SARS-CoV-2 infection share several clinical features, potentially posing a diagnostic challenge. A 24-year-old man without significant medical history presented with fever, worsening cough, dyspnea, vomiting and diarrhea during a local peak of COVID-19 cases. He required 10 liters of supplemental oxygen due to hypoxemic respiratory failure. Laboratory workup revealed: leukocytosis (ANC 15,200 cells/microliter), elevated ESR/CRP, ferritin-1030 ng/mL, d-dimer-791 ng/mL, procalcitonin-0.8 ng/mL, mild transaminitis, elevated IL-6 (173 pg/mL). Six nasopharyngeal PCR assays did not detect SARS-CoV-2 (2 prior to admission). Chest computed tomography delineated diffuse patchy ground glass opacities with shotty mediastinal and hilar lymphadenopathy. The working diagnosis was COVID-19 disease, however the patient subsequently admitted to frequent vaping of cannabis and THC-oils. He clinically improved after receiving antibiotics and steroids for treatment of EVALI. Similar to COVID-19, EVALI has a broad spectrum of pulmonary findings and may be accompanied by gastrointestinal or constitutional manifestations, elevated inflammatory markers and non-specific imaging. Leukocytosis with neutrophilic predominance is found in EVALI. The proposed immunopathology of lung damage in EVALI is via a cytokine cascade of IL-1, IL-6, and IL-13. COVID-19 may portend a detrimental cytokine storm syndrome. Elevated peripheral IL-6 levels can be detected in both diseases; this patient had a markedly elevated level suggesting a cytokine storm-like picture. The overall features of this case suggested EVALI, illustrating the importance of its consideration in the differential diagnosis of SARS-CoV-2 infection.