SMOKE EVERYWHERE, FROM LUNGS TO SPINE!

Abstract

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: E-Cigarette/Vaping associated Lung Injury (EVALI) has presented with no pattern of disease progression.Availability of e-cigarettes since 2007 in the US have seen a rise in demand in younger age group, reported use by 20.8% high schoolers in 2018. (1) CASE PRESENTATION: 19-year-old male presented with nausea, vomiting, diarrhea, dyspnea, chest pain.Physical examination-saturation 77% on room air, decreased bilateral breath sounds, crackles and sinus tachycardia. Initial chest x-ray(CXR) showed bilateral pneumothorax, pneumomediastinum, extensive subcutaneous emphysema to neck, upper back. CT chest was consistent with CXR and diffuse bilateral ground glass opacities on lower lobes. No evidence of recent travel, infections, drug use, smoking history was reported. Boerhaave syndrome from vomiting was ruled out with CT oral contrast without esophageal leak. He eventually admitted to vaping tetrahydrocannabinoid (THC) products three times daily for last 3-4 weeks. Started on high dose methylprednisone 125 mg every 6hours. He worsened to severe acute respiratory distress syndrome requiring bilateral 32Fr chest tubes, with PaO2/FiO2 69 while on ventilatory support with PEEP of 10cm of water, FiO2 100%.CT head and spine showed air in the subcutaneous tissues of skull base, neck, orbits and epidural space of spinal canal confirming to our knowledge the first ever case of Pneumorrhachis secondary to EVALI. DISCUSSION: EVALI is worldwide phenomenon with more concentration in Illinois and Wisconsin.EVALI is diagnosis of exclusion in absence of infectious/autoimmune causes and direct correlation with vaping THC with/without nicotine.Different combinations used are nicotine, THC, dank vapes, dabbing, cannabinoid oil.[1,2]Unregulated THC products contain Vitamin E acetate which is the culprit agent. An accurate pathophysiology is still to be determined but possibility of lipoid pneumonia,subacute bronchial toxicity,respiratory bronchiolitis–interstitial lung disease, bronchiolitis obliterans organizing pneumonia, diffuse alveolar hemorrhage, acute eosinophilic and acute hypersensitivity pneumonia have been discussed.[3]Although controversial due to nonspecific,evidence of macrophages with lipid deposition in bronchoalveolar lavage(BAL) is seen.Urine has higher sensitivity compared to BAL for THC analysis.CT ranges from infiltrates, consolidations, air bronchograms, ground glass opacities more in lower lobes. Pneumorrhachis, an extremely rare phenomenon of air in the spinal canal, is likely result of high-pressured alveolar rupture.This however, is likely the first ever reported case of pneumorrhachis secondary to EVALI. Like EVALI,no guidelines exist for pneumorrhachis due to rare incidence but conservative course has been reported previously. CONCLUSIONS: These findings in a healthy young male show, vulnerability and unpredictable disease course of EVALI, with no recommended guidelines for management yet. Reference #1: Dinardo P, Rome ES. Vaping: The new wave of nicotine addiction. Cleve Clin J Med. 2019;86(12):789-798. doi:10.3949/ccjm.86a.19118 Reference #2: Kalininskiy A, Bach CT, Nacca NE, et al. E-cigarette, or vaping, product use associated lung injury (EVALI): case series and diagnostic approach. Lancet Respir Med. 2019;7(12):1017-1026. doi:10.1016/S2213-2600(19)30415-1 Reference #3: Ghinai I, Pray IW, Navon L, et al. E-cigarette Product Use, or Vaping, Among Persons with Associated Lung Injury - Illinois and Wisconsin, April-September 2019. MMWR Morb Mortal Wkly Rep. 2019;68(39):865-869. Published 2019 Oct 4. doi:10.15585/mmwr.mm6839e2 DISCLOSURES: No relevant relationships by Habiba Hussain, source=Web Response No relevant relationships by Matthew Sehring, source=Web Response No relevant relationships by Deepak Taneja, source=Web Response