P1040 - Adolescent EVALI in the Delaware Valley: A Report of 9 Cases

Introduction: E-cigarette or vaping use-associated lung injury (EVALI) is an increasing concern in pediatrics due to a sharp uptick in use of nicotine and cannabis-containing products and an influx of respiratory related hospitalizations first noted in June 2019. There are few published reports describing the clinical features, co-morbidities, severity of disease and outcomes of treatment in adolescents. This report describes the experience of a single tertiary care children’s hospital in the Delaware Valley and reviews data from all patients diagnosed with EVALI from July 2019 to January 2020 at the Nemours-Alfred I. duPont Hospital for Children in Wilmington, Delaware. Demographic, clinical, therapeutic, diagnostic features and outcomes are presented.


Case Description: Nine patients diagnosed with EVALI during the study period are included. All were male (mean age 16.4yr range 14-18yr). Eight were Caucasian, while one was Hispanic. All denied prior pulmonary conditions, mental health comorbidities were noted in five. Fever and GI symptoms were the most common presentation (n= 8). Cough was the most common respiratory symptom (n=5). Chest pain and dyspnea were less frequent (n=2). Significant weight loss was also noted (n= 4). Marijuana use alone was endorsed in four patients, nicotine use in one, and use of both in four. All UDS were positive for THC (n=5). Duration of vaping ranged from 3-months to 1-year (n=7). Eight patients were hospitalized (n=8); often with the need for respiratory support (BLPAP: n=1; CPAP: n=1, HFNC: n=1, Standard nasal cannula: n=1). Chest X-ray findings were often mild and non-specific (n=8). One patient had a normal chest x-ray. Chest CT changes including multifocal, bilateral, groundglass opacities were noted in all patients (n=9), with subpleural sparing less commonly described (n=3). Inflammatory markers (ESR/CRP) were elevated when measured (n=6). Spirometry was performed at presentation in six patients; five showed airway obstruction. Hospitalized patients were treated initially with methylprednisone and transitioned to prednisone prior to discharge. All patients seen in follow up in pulmonology clinic had improved symptoms and normal spirometry (n=8). Hospital readmission occurred in two patients, both reported vaping relapse.


Discussion: This cohort of male adolescents with EVALI showed favorable response to steroids and abstinence from vaping with minimal evidence of permanent lung injury. Readmission was related to recurrent vaping. Abnormal chest CT and elevated inflammatory markers were the most consistent diagnostic findings. While fever and GI symptoms were common, the clinical presentation and symptoms were variable.


Conclusion: Pediatricians need to maintain a high index of suspicion and consider EVALI in adolescents with vague systemic symptoms. CT scan was more sensitive than plain film in detecting EVALI-related pulmonary disease and ESR and CRP were clinically helpful. Long-term outcomes were reassuring.