E-cigarette or Vaping Product Use Associated Lung Injury (EVALI) in Teenager After Reported COVID-19 Infection

Introduction: E-cigarette or vaping product use associated lung injury (EVALI) is a relatively new pulmonary syndrome linked to e-cigarette consumption. As of February 18th, 2020, a total of 2,807 hospitalized EVALI cases have been reported to the CDC. Among hospitalized EVALI cases, 15% (421 patients) were under the age of 18.

Case Description: Patient is a 17-year-old previously healthy male who presented to the ED for a 3-day history of fever, progressively worsening nausea and vomiting, anorexia, dry cough, and night sweats. PMH was significant for COVID-19 infection in April 2021 and he was fully vaccinated for COVID-19 as of May 2021. Patient also noted 10 lbs. unintentional weight loss in the last month. Patient denied substance use or sexual activity. Family history was unremarkable. In the ED the patient was febrile and mildly tachycardic. Physical exam was grossly unremarkable including a normal lung exam. Relevant labs revealed a leukocytosis, hyponatremia, elevated ESR and CRP. SARS-COVID-2 PCR negative, SARS-COVID-2 IgG S1/S2 Spike protein positive, nucleocapsid negative. CXR, ECG, and RUQ U/S were unremarkable. Patient was subsequently admitted to the inpatient pediatric service for further management.
During hospitalization the patient reported increased shortness of breath and pleuritic chest pain with SaO2 down to 86% on room air requiring supplemental oxygen. New social history obtained without family present revealed heavy vaping of nicotine and THC ‘most days’ for the past 3 years. Pediatric pulmonology was consulted and diagnosed the patient with EVALI and started him on methylprednisolone and a 5-day course of azithromycin for its anti-inflammatory effects. The patient was subsequently able to be weaned off oxygen and was discharged home on an oral prednisone taper and azithromycin after 6 days in the hospital. CXR 2 weeks after discharge was normal with complete resolution.

Discussion: EVALI is mainly a diagnosis of exclusion and can mimic other infectious and rheumatologic conditions, therefore clinicians must maintain a high index of suspicion in order to make the diagnosis.

Clinical manifestations of EVALI can include respiratory, gastrointestinal, and constitutional symptoms. The most frequently reported symptoms include shortness of breath, fever, cough, vomiting, diarrhea, dizziness, headache, tachycardia, and chest pain. Laboratory studies often show an elevated CRP and procalcitonin, leukocytosis, and a transaminitis. Radiographic features can include diffuse, bilateral, ground-glass infiltrates with basilar predominance and sub-pleural sparing.

Conclusion: This case demonstrates the importance of obtaining a social history in a confidential environment in any adolescent case. When this was done on hospital day two, we learned of an extensive vaping history which helped us diagnose the patient with EVALI. In addition to drug use, clinicians should specifically ask about the use of e-cigarettes and vaping products since not all adolescents will divulge these details unless directly asked.