TOPIC: Tobacco Cessation and Prevention
TYPE: Fellow Case Reports
INTRODUCTION: Vaping is the process of generating an aerosol by heating a liquid or wax and inhaling the substance with a battery-operated device. E-cigarette, or vaping, product use associated lung injury (EVALI) is an acute or subacute respiratory illness that can be potentially severe and life threatening. Presented is a case of EVALI which illustrates the importance of recognizing and managing the disease process.
CASE PRESENTATION: A 32-year-old female with no past medical history presented to the hospital with occipital headache, neck pain and weakness for a 2-week duration. Patient initially underwent an LP which was unremarkable for bacterial or viral meningitis. Over the next 24 hours, the patient subsequently developed a fever of 101.8 Fahrenheit, worsening leukocytosis and dyspnea. Patient had a CT chest with contrast which showed multiple small pulmonary nodules with bilateral interstitial and ground-glass opacities. During admission patient developed worsening hypoxic respiratory failure requiring endotracheal intubation. Patient underwent endobronchial ultrasound with bronchoalveolar lavage sampling, fine needle aspiration of the subcarinal lymph node and transbronchial biopsy of the right middle lobe. Patient was treated in the ICU with broad spectrum antibiotics and systemic glucocorticoids. Lab evaluation for bacterial and viral pathogens as well as vascular and rheumatological disease were all negative. Patient had subsequent improvement in bilateral interstitial infiltrates and respiratory status and was extubated without complication. Following extubation further history revealed extensive vaping history over the past 6 months consistent with a diagnosis of EVALI. The patient was treated with systemic glucocorticoids with transition to oral steroid taper and discharged home without complication. Imaging three months after discharge showed complete resolution of bilateral interstitial infiltrates.
DISCUSSION: Pulmonary illness related to e-cigarette or vaping use had previously seen an increasing incidence within the United States. EVALI remains a diagnosis of exclusion with history consistent with vaping use within the past 90 days and lung opacities on imaging. Systemic glucocorticoids are the recommended treatment for patients developing worsening dyspnea and respiratory failure.
CONCLUSIONS: This case illustrates the importance of obtaining pertinent history related to e-cigarette and/or vaping use. This case also demonstrates recognizing EVALI as a steroid-responsive disease and its potential to lead to severe and life-threatening complications.
REFERENCE #1: Layden JE, Ghinai I, Pray I, Kimball A, Layer M, Tenforde MW, Navon L, Hoots B, Salvatore PP, Elderbrook M, Haupt T, Kanne J, Patel MT, Saathoff-Huber L, King BA, Schier JG, Mikosz CA, Meiman J. Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin - Final Report. N Engl J Med. 2020 Mar 5;382(10):903-916. doi: 10.1056/NEJMoa1911614. Epub 2019 Sep 6. PMID: 31491072.
REFERENCE #2: Schier JG, Meiman JG, Layden J, Mikosz CA, VanFrank B, King BA, Salvatore PP, Weissman DN, Thomas J, Melstrom PC, Baldwin GT, Parker EM, Courtney-Long EA, Krishnasamy VP, Pickens CM, Evans ME, Tsay SV, Powell KM, Kiernan EA, Marynak KL, Adjemian J, Holton K, Armour BS, England LJ, Briss PA, Houry D, Hacker KA, Reagan-Steiner S, Zaki S, Meaney-Delman D; CDC 2019 Lung Injury Response Group. Severe Pulmonary Disease Associated with Electronic-Cigarette-Product Use - Interim Guidance. MMWR Morb Mortal Wkly Rep. 2019 Sep 13;68(36):787-790. doi: 10.15585/mmwr.mm6836e2. Erratum in: MMWR Morb Mortal Wkly Rep. 2019 Sep 27;68(38):830. PMID: 31513561; PMCID: PMC6755818.
REFERENCE #3: Davidson K, Brancato A, Heetderks P, Mansour W, Matheis E, Nario M, Rajagopalan S, Underhill B, Wininger J, Fox D. Outbreak of Electronic-Cigarette-Associated Acute Lipoid Pneumonia - North Carolina, July-August 2019. MMWR Morb Mortal Wkly Rep. 2019 Sep 13;68(36):784-786. doi: 10.15585/mmwr.mm6836e1. PMID: 31513559; PMCID: PMC6755817.
DISCLOSURES: No relevant relationships by Muhammad Ehtesham, source=Web Response
No relevant relationships by Eric Hart, source=Web Response
No relevant relationships by Amin Pasha, source=Web Response
© 2021 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.