TOPIC: Tobacco Cessation and Prevention
      TYPE: Medical Student/Resident Case Reports
      INTRODUCTION: Electronic nicotine delivery systems (ENDS) are often marketed and promoted as a "safe alternative" to smoking. This marketing strategy has led to many young smokers switching or even starting ENDS use. Traditional smoking is a known risk factor for the development of oral candidiasis or "thrush." So far, bench research has suggested, and experts have speculated that electronic nicotine delivery systems could be a risk factor for oral candidiasis. However, no cases have been reported in the literature to suggest this as a risk factor. Here, we present a case report of a young, healthy adult with severe oral candidiasis after daily use of electronic cigarette or vaping for past three months.
      CASE PRESENTATION: This is an 18-year-old male with no past medical history other than electronic cigarette or vaping use who presented to emergency department with odynophagia, stomatitis, and xerostomia. Patient had failed outpatient therapy with antibiotics as he was misdiagnosed at an urgent care with gingivitis, which led to this hospital admission. He denied any use of inhaled steroids outpatient. On physical exam, purulent discharge on lips with associated angular cheilitis was noted. Patient had white lesions on the tongue and mouth that were easily scrapeable and revealed pinpoint bleeding. Tonsils were not swollen but he had difficulty swallowing. Mildly enlarged cervical lymph nodes were seen on CT neck without evidence of pharyngeal abscesses. Subsequently based on clinical presentation and history of using electronic vaping, he was diagnosed with severe oral candidiasis and was started on intravenous fluconazole, swish and spit topical analgesia. Patient was negative for HIV with normal CD4+ count. The rest of sexually transmitted infection work up was negative. During the hospital stay, patient was treated with intravenous fluconazole for four days which was transitioned to p.o. antifungal after patient was able to tolerate oral intake. Subsequently he was discharged with six more days of oral antifungal along with E-vaping cessation counseling. Patient records noted complete resolution of symptoms in two weeks on outpatient evaluation.
      DISCUSSION: This case report is important as it highlights electronic cigarette or vaping use as a risk factor for oral candidiasis, which physicians needs to be aware of as a differential. As electronic nicotine delivery systems (ENDS) become increasingly popular, especially with younger patients, healthcare providers must be informed to better counsel their patients on the risks and benefits of electronic cigarette or vaping use, and encourage ENDS cessation.
      CONCLUSIONS: Our case report attempts to add clinical data to explore nicotine delivery systems (ENDS) as a new risk factor for oral candidiasis in younger population. Additionally, we propose a name for this newly described condition: E-cigarette or Vaping use-associated Oral Candidiasis or EVAOC.
      REFERENCE #1: Vila T, Sultan AS, Montelongo-Jauregui D, Jabra-Rizk MA. Oral Candidiasis: A Disease of Opportunity. J Fungi (Basel). 2020;6(1):15. Published 2020 Jan 16. doi:10.3390/jof6010015
      REFERENCE #2: Alanazi H, Semlali A, Chmielewski W, Rouabhia M. E-Cigarettes Increase Candida albicans Growth and Modulate its Interaction with Gingival Epithelial Cells. Int J Environ Res Public Health. 2019;16(2):294. Published 2019 Jan 21. doi:10.3390/ijerph16020294
      REFERENCE #3: Wang TW, Neff LJ, Park-Lee E, et al. E-cigarette Use Among Middle and High School Students — United States, 2020. Morbidity and Mortality Weekly Report, 2020;69.
      DISCLOSURES: No relevant relationships by Maria Baldino, source=Web Response
      No relevant relationships by Prateek Juneja, source=Web Response
      No relevant relationships by Peter Pietrandrea, source=Web Response
      No relevant relationships by Lin Zheng, source=Web Response