P1046 - EVALI in an 18-Year-Old Male with Abdominal Pain

INTRODUCTION
E-cigarette or vaping associated lung injury (EVALI) is a new condition characterized by the CDC as a potentially life-threatening respiratory illness linked to vaping. Patients may present with a wide range of influenza-like symptoms. Abdominal pain, nausea and vomiting were the predominant symptoms in this case of suspected EVALI.

CASE DESCRIPTION
An 18-year-old male with a two-year history of intermittent nausea, vomiting and abdominal pain, presented to the ED with worsening nausea and vomiting despite oral antiemetics and five days of fever. He had normal vitals, and exam was significant only for mild nonspecific abdominal tenderness. Initial labs revealed leukocytosis, anemia and elevated inflammatory markers. CT of the chest and abdomen performed to rule out malignancy revealed a normal abdomen but extensive bilateral patchy and ground glass airspace opacities. He was started on antibiotics for presumed multifocal pneumonia. Shortly after admission, he developed shortness of breath and chest tightness without tachypnea or hypoxemia. A detailed adolescent history revealed extensive vaping use for several years, but he reported quitting 6 weeks prior to admission. Infectious workup was negative. The bronchoalveolar lavage revealed many lipid laden macrophages. His PFTs showed a severely restrictive respiratory process. Due to high suspicion for EVALI, antibiotics were discontinued and he was started on intravenous methylprednisolone. Within 24-48 hours he was able to tolerate a regular diet with resolution of fever and significant improvement of respiratory and gastrointestinal symptoms. He was discharged home on a prednisone taper. The patient’s vaping cartridges sent to the CDC tested positive for vitamin E acetate, tetrahydrocannabinol, medium-chain triglycerides, and nicotine. At his 1 month follow up, he continued to abstain from vaping, his repeat PFTs had normalized, and he remained asymptomatic with complete return of his appetite.

DISCUSSION
As of February 18, 2020, there have been over 2,800 reported hospitalized cases of EVALI in the U.S., including 68 deaths, with 52% of all patients aged 24 and younger. To diagnose EVALI, e-cigarette use must be within 90 days of symptom onset, and infectious etiologies should be ruled out as presenting symptoms can be similar and may overlap. Corticosteroids may be helpful in treatment of EVALI. Ultimately, discontinuation of vaping is essential. Vitamin E acetate, an additive in e-cigarettes, has been found in the majority of samples analyzed by the CDC, but other components may also contribute to the clinical picture.

CONCLUSION
Patients with EVALI can present with respiratory, gastrointestinal or constitutional symptoms and they do not have to be actively vaping to develop symptoms. Gastrointestinal symptoms may also precede respiratory symptoms. It is important to take a thorough social history on all patients regarding e-cigarette/vaping use and have a high index of suspicion, especially in this age group.