Case Presentation: There has been an increasing number of cases of e-cigarette, or vaping, product use associated lung injury (EVALI) in the United States; however, much is still unknown about the disease. Thus far, most cases have occurred in individuals under the age of 35 with a history of tetrahydrocannabinol (THC) vaping. A 32 year-old Caucasian female with a past medical history of migraines, GERD, and obesity presented to the emergency department with two days of shortness of breath associated with fever, chills, and a nonproductive cough. She denied tobacco use or occupational exposures butreported excessive vaping with illicit THC oil. On exam, she was tachycardic, tachypneic, febrile (101 degrees Fahrenheit) and had an oxygen saturation of 93% on room air; lung exam revealed fine crackles bilaterally with an expiratory wheeze. Laboratory results included white blood cellcount of 20.99, erythrocyte sedimentation rate (ESR) greater than 120, C-reactive protein (CRP) 288.0, brain natriuretic peptide 689, and negative troponin. A chest CT with angiography was negative for pulmonary embolism but showed diffuse pulmonary edema; a bedside echocardiogram did not show evidence of heart failure. An arterial blood gas revealed PaO2/FiO2 ratio of 173. The patient was admitted for acute respiratory distress syndrome (ARDS); her respiratory status shortly deteriorated and she was placed on mechanical ventilation and started on systemic steroids and antibiotics. Further testing including sputum and blood cultures and influenza swab were negative. Due to minimal improvement over the subsequent days, she was transferred to a tertiary care center for potential extracorporeal membrane oxygenation (ECMO). At the center, she did not require ECMO as her respiratory status improved. However, her course was complicated by multiple cerebral vascular accidents with subsequent deficits to visual tracking. She remains hospitalized with planned transfer to a rehabilitation facility.
Discussion: EVALIs are increasingly prevalent in 2019; most patients are in their twenties or thirties with a history of vaping products containing illicit THC. While the pathogenesis is not clear, a number of poorly-understood chemicals associated with illicit THC-containing products are believed to be the cause. EVALI patients typically present with respiratory and constitutional symptoms while exam findings include hypoxia, tachypnea, and diffuse bilateral rales and rhonchi. Laboratory findings include leukocytosis and elevated inflammatory markers, such as ESR and CRP, without a clear infectious etiology. Radiographic studies usually reveal diffuse bilateral ground glass opacities. There are no formal diagnostic criteria for EVALI and it is mostly adiagnosis of exclusion. Optimal treatment for EVALI is unknown; management includes adequate ventilation and possibly systemic steroids. Given the novelty of EVALI, the prognosis for patients is not well documented. As of October 2019, there were 1604 cases reported to the CDC, 34 of which resulted in mortality.
Conclusions: Physicians should keep EVALI high on their differential for patients who present with respiratory complaints in the setting of a history of vaping illicit substances.