Case Presentation: KM is a 13-year-old woman with no past medical history who presented with 1 week of daily vomiting, epigastric abdominal pain, and body aches. On review of systems has also had fever to 100.7, decreased oral intake, shortness of breath with activity and intermittent diarrhea but no headache, sore throat, wheezing or rash. She tested negative for covid twice at home. She is home schooled and her sister is her legal guardian due to recent death of her mother from cancer. No family history of inflammatory or autoimmune disease. Patient denied any smoking, vaping, alcohol or drug use on presentation when interviewed alone. She was not vaccinated for Covid-19. She has been around people who have tested positive for covid recently but no household contacts. She was dehydrated on exam with tachycardia to 150s. She was dyspneic and hypoxic to the mid 80s with ambulation. Lung exam demonstrated decreased breath sounds and crackles at the bases. Her labs on admission to the community pediatric hospital were notable for WBC of 10, K 2.9, troponin 4, Pro BNP 914, CRP 92mg/L, D dimer 2.62mg/mL, procalcitonin 0.82 ng/mL. Initial EKG showed sinus tachycardia. She had a chest xray which showed patchy infiltrates consistent with viral illness. Extended viral respiratory panel negative. Covid Ab was positive but PCR negative. She was started on remdesivir and dexamethasone due to concern for possible covid pneumonia and ampicillin and azithromycin for community acquired pneumonia in consultation with infectious disease. Due to concern for multisystem inflammatory syndrome of children (MIS-C) given elevated D-dimer and inflammatory markers she was transferred to a tertiary care center for an echocardiogram and subspecialist consultation. CT chest showed diffuse interstitial infiltrates and ground glass opacities and was negative for pulmonary embolism. TTE was normal. SHe was treated with 1 dose of IVIG, lovenox and ASA for potential treatment of MIS-C. Upon discussion with pediatric radiology the appearance of the ground glass opacities on CT was concerning for e-cigarette or vaping product use-associated lung injury (EVALI). Upon further discussion, patient admitted to vaping regularly for the past few months. She completed a course of azithromycin and was discharged home with pulmonary follow up.
Discussion: Both MIS-C and EVALI are diagnoses of exclusion and have many overlapping features. Patients with EVALI tend to have a neutrophilic leukocytosis as well as an absence of recent Covid-19 infection. In addition, while both entities can cause ground glass opacities on imaging, patients with EVALI typically have some subpleural sparing on CT.
Conclusions: Pediatric hospitalists in the 21st century have two emerging diseases, MIS-C and EVALI, that have significant overlap. This case demonstrates the clinical overlap between MIS-C and EVALI from both a symptom and labwork perspective. It is only through the imaging and a thorough and accurate social history that the diseases can be distinguished.