Case Presentation: A 37-year-old male auto-mechanic, with a history of tobacco use, presented with acute right-sided pleuritic chest pain. He was diagnosed with musculoskeletal pain and discharged from the ED. Several days later he returned with dyspnea, dry cough, fever and diaphoresis. He revealed that he recently tried vaping marijuana (THC) oil. Vital signs were temperature of 101.9 F, HR 111 bpm, BP 131/80, RR 38/min, and 91% oxygen saturation on room air. He appeared acutely ill and had poor diaphragmatic excursion and diminished breath sounds. Laboratory studies were significant for WBC 9.7/mm3 (69% segs, 16% lymphs, 14% monos), creatinine 1.28 mg/dL, BNP 58 pg/mL, procalcitonin 0.15 ng/mL, D-dimer 192 ng/mL, troponin T gen 5 <6 ng/L, and ABG 7.43/41/83/27/3.1 on 2 liters supplemental oxygen. CT chest with IV contrast showed multifocal consolidation with areas of central low attenuation and fat attenuation. IV vancomycin, ceftriaxone, and azithromycin were started. But, his clinical condition worsened and he was transferred to the ICU for high flow oxygen. Microbiologic and serologic evaluations for infection were negative. EVALI (E-cigarette or Vaping Product Use Associated Lung Injury) was suspected and an intravenous steroid was prescribed with subsequent rapid clinical improvement. He was discharged on a steroid taper for probable vaping-associated lung injury.

Discussion: Our patient presented with severe right-sided chest pain which was initially misdiagnosed as musculoskeletal pain but turned out to be EVALI. He is just one of the hundreds of cases that comprise a national outbreak that began to accelerate in July 2019. At the time of this submission, 1,080 cases of e-cigarette associated lung injury have been reported across 48 states with 18 confirmed deaths. CDC and state health departments are currently collecting epidemiologic data. The specific chemical causing this outbreak is thus far unknown. Epidemiology, clinical features, pathophysiology, treatment and prognosis are not well-established. Based on information from a handful of cases series and CDC updates, general trends have been identified. Most patients are young and healthy. All report a history of e-cigarette use with either THC or a tobacco-containing product. Patients can present with acute to subacute onset of fever, cough, dyspnea, nausea, vomiting, and/or diarrhea. Typical chest imaging shows bilateral pulmonary infiltrates. Infectious workup is almost always negative. A recent case series described the finding of foamy macrophages and pneumocyte vacuolization in lung biopsies from patients with a confirmed diagnosis, but uniform histologic criteria was not defined.

Conclusions: EVALI should be suspected when there is a history of e-cigarette use within 90 days of symptom onset, imaging shows lung injury, infectious work up is negative and an alternative diagnosis is unlikely. Our patient is just one of the many who are a part of a national outbreak of EVALI. In the context of this novel public health crisis, Hospitalists have a central role in recognizing this diagnostic entity, reporting cases for ongoing study, counseling patients on the perils of e-cigarette and vaping exposure, and discouraging use of these products to those not yet affected by this illness.