378 - E-cigarette or Vaping Associated Lung Injury in the Time of COVID-19

Background: Pediatric providers have been caring for two new and similar respiratory illnesses: E-cigarette or vaping use associated lung injury (EVALI) beginning in 2019 and Coronavirus Disease 19 (COVID-19) in 2020. Similarities include prodrome, presentation, imaging, and laboratory testing. While EVALI often improves with steroid treatment, steroids can be detrimental early in the course of COVID-19.
Although a positive SARS CoV-2 polymerase chain reaction (PCR) test is helpful, this result does not definitively identify SARS CoV-2 as the primary cause of symptoms in patients with a history of vaping, as both processes may be coexistent.  Coinfection with other infectious agents is commonly found in children with COVID-19 infection, and the majority of children with PCR positive SARS CoV-2 are asymptomatic or mildly symptomatic. 

Methods: In hopes of better defining EVALI versus COVID-19 clinical syndromes, we reviewed charts of pediatric patients admitted to a freestanding children’s hospital in Texas diagnosed with EVALI over a year period from June 1, 2019 and June 1, 2020.  Cases were identified through a local patient registry. We compared findings in these cases with literature regarding pediatric patients with acute COVID-19 and EVALI. Variables included presenting symptoms, timing of symptoms, vital signs, imaging, and laboratory results. 

Results: Twelve patients with EVALI diagnosis were included. Clinical presentation, imaging, and laboratory findings were similar to those described with acute COVID-19 and are included in figures 1 and 2. Repeated interviewing regarding vaping revealed a history of vaping in all EVALI cases; frequency reported varied from multiple times daily to remote use. Some cases with EVALI also had a significant psychiatric history, positive urine drug screen, or significant weight loss prior to hospitalization. Cases with EVALI and steroid treatment improved within days of treatment. In a review of literature, BAL sampling often reveals lipoid pneumonia in EVALI cases, which would not be expected in COVID-19. Of note, the single case in our group tested did not have lipoid pneumonia on bronchoalveolar lavage (BAL) cytology. fig 2. Laboratory Findings Among 12 cases with EVALI
Figure 1. EVALI Case Presentation and Description


Conclusion: Presence of prolonged preceding weight loss, or BAL cytology could help differentiate these clinical states.