TOPIC: Tobacco Cessation and Prevention
      TYPE: Medical Student/Resident Case Reports
      INTRODUCTION: Electronic cigarette or vaping product use associated lung injury (EVALI) has received increasing attention by the Centers for Disease Control and Prevention (CDC) within the last year due to a recent increase of cases of acute lung injury associated with vaping. The CDC has established criteria for EVALI: 1) the patient must have vaped within 90 days prior to symptom onset; 2) there is evidence of pulmonary infiltrate on chest radiographs or chest CT; 3) absence of pulmonary infection on initial work-up; 4) no evidence alternative diagnoses.Spontaneous pneumothoraces (SPs) are often idiopathic in nature, classically in tall, thin males between the ages of 15-34 years old, as well as underlying lung or connective tissue diseases. There are few reported cases of SPs in association with vaping or e-cigarette use, with bilateral pneumothoraces being nearly unseen.
      CASE PRESENTATION: A 26-year-old Caucasian male with past medical history of polysubstance abuse presented to the emergency department with a one-day history of shortness of breath and chest pain. He was an active daily vaper. On arrival, he endorsed dyspnea, hemoptysis, presyncope, and pleuritic pain. Vitals showed hypotension, tachycardia, and tachypnea. Physical exam shows no trauma or tracheal deviation. Lung sounds were decreased at both apices. Chest X-ray showed bilateral apical pneumothoraces. Workup for respiratory virus panel and COVID were negative. CBC and CMP lab values were largely unremarkable, only with lactic acidosis to 4.4 mmol/L. Toxicology was positive for cocaine, THC, and opiates. A left sided thoracostomy was performed, resulting in resolution of the left sided pneumothorax. Shortly after placement, the patient traumatically removed his thoracostomy tube. 100% oxygen resulted in resolution of the right sided pneumothorax. The patient was downgraded from the ICU and discharged on hospital day three with resolution of symptoms.
      DISCUSSION: Spontaneous pneumothorax is a potentially life-threatening emergency condition. This patient's concerning presentation with spontaneous bilateral secondary pneumothoraces (SBSP) and multifocal opacities on the chest x-ray in the setting of vape use, without a prior or family history of lung disease, created a concerning clinical picture. EVALI is already a concerning condition. Per the CDC as of January 14, 2020, there were 2,668 cases of EVALI requiring hospitalization, with 68 cases resulting in mortality
      CONCLUSIONS: This case is highlighted in order to add to increasing evidence of the dangerous effects of vaping. Patients should be counseled on the wide variety of risks of vaping. Furthermore, cases of SBSP are quite rare, and this patient's history makes vaping and marijuana use the most likely contributing factors to his presentation. Patients with a history of spontaneous pneumothorax should be monitored over time for recurrences and counseled on vaping cessation.
      REFERENCE #1: Outbreak of Lung Injury Associated with the Use of E-Cigarette, or Vaping, Products.
      REFERENCE #2: Graf-Deuel E, Knoblauch A: Simultaneous bilateral spontaneous pneumothorax. Chest. 1994, 105:1142-1146. 10.1378/chest.105.4.1142
      DISCLOSURES: No relevant relationships by Riley Ewen, source=Web Response
      No relevant relationships by Gilad Guez, source=Web Response
      no disclosure on file for Brijesh Patel;
      no disclosure on file for Farhan Shah;