P0906 - What's lungs got to do, got to do with it? A 13-year-old male with vomiting and abdominal pain

Introduction: A 13-year-old male presented with acute on chronic vomiting and abdominal pain. What should we be considering in our broad differential?

Case description: Three months ago, he was hospitalized for epigastric/RUQ pain, fever, and emesis. He improved with antibiotics and supportive care and was discharged with a diagnosis of infectious gastroenteritis. Three days ago, he began having severe LUQ pain, nonbloody diarrhea, nausea, and NBNB emesis. Parents noted ~10lbs of weight loss in the last few months. ROS negative for recent fevers, night sweats, chest pain, shortness of breath, and tobacco/drug/alcohol use.

Physical exam:
Vital signs were BP 133/77, HR 97, T 37.5 °C, RR 20, and SpO2 97% on RA. Examination showed an uncomfortable and diaphoretic male writhing in bed with pain. Abdomen was soft with active bowel sounds, extreme tenderness to light palpation in the LUQ, without guarding or rebound, and without CVA tenderness. Cardiac examination showed sinus tachycardia without murmurs. Respiratory and genitourinary exams were normal.

Diagnostic evaluation:
Given initial presentation of abdominal pain, nausea, vomiting, and weight loss, he was initially worked up for a GI cause of his complaints, with concern for IBD or infectious etiology. CT abdomen/pelvis was unremarkable. Given negative GI work-up, Rheumatology was consulted with negative workup for auto-immune processes or vasculitis. On hospital day 1, he became hypoxic to 72% and required 4L of supplemental O2. CXR was normal. Pulmonology was consulted, and upon specific questioning, the patient admitted to frequent daily vaping. Chest CT demonstrated bilateral ground glass opacities/crazy paving (Image 1) consistent with e-cigarette, or vaping, product use-associated lung injury (EVALI).

Diagnosis: E-cigarette, or vaping, associated lung injury (EVALI)

Discussion:
EVALI is an emerging threat to pediatric patients that typically presents with fever, cough, headache, and myalgias. In this case, the patient’s long-standing GI complaints obscured the picture, though case series show 57% EVALI cases present with GI complaints. In addition, 15% did not have any respiratory symptoms, and 38% had a normal CXR and abnormal CT chest.

This patient had been asked about and denied smoking in a private interview on admission. Not until pulmonology was consulted did we discover he had been vaping daily. Many teens consider vaping to be different from smoking. One study showed that 40% of teens who use vaping devices do not know that e-cigarettes contain nicotine, underscoring the need to ask specifically about vaping.

Conclusion: Pediatricians should screen all patients specifically for e-cigarette use and consider EVALI in the differential for adolescents presenting with abdominal pain even in the absence of respiratory symptoms.