Case Presentation: A 29-year-old male with no significant past medical history was admitted with 10 days of persistent fevers, cough, shortness of breath that worsened with exertion, weight loss, nausea, and vomiting. The patient had no history of travel to any TB-endemic areas, was in a monogamous relationship with his wife, denied IVDU, and had no family history of lung disease or cancer. He smoked cigarettes in college but transitioned to vaping e-cigarettes. On presentation to the hospital the patient was febrile to 38.9°C, and hypoxemic with exertion with an oxygen saturation in the low 80s on 2L of oxygen via nasal cannula. His labs were significant for elevations in ESR, CRP, LDH, with decreased T-cell lines, and respiratory viral panel positive for enterovirus with serology positive for Coxsackie B. A CT chest showed diffuse ground glass opacities in the lower lobes bilaterally. Initially, the patient was started on empiric antibiotics for community acquired pneumonia. Sulfamethoxazole and trimethoprim and steroids were also started for the possibility of PCP pneumonia, but sulfamethoxazole and trimethoprim was discontinued after the negative HIV test. A bronchoalveolar lavage was unrevealing, and all other autoimmune studies were negative. The patient clinically improved after a short course of steroids and empiric antibiotics, and was discharged home.

Discussion: With over 1400 cases reported to the CDC, vaping-associated pulmonary injury (VAPI) is an emerging serious condition with varying degrees of severity. This case highlights a unique presentation of a Coxsackie B viral infection superimposed on vaping-induced lung injury in an otherwise healthy, young male. It is unknown if the patient’s T-cell abnormality was secondary to the viral infection, or if it was a result of a chemical in the vape. This case should serve as a reminder that although the pathogenesis of VAPI is not yet well understood, the clinical presentations can present very widely including severe immunosuppression and superimposed infection, as seen in this case.

Conclusions: VAPI is a rising cause of hospitalizations in the United States. This case highlights that vaping can lead to severe lung injury with immunosuppression and superimposed infection. Future cases of VAPI should assess for immunosuppression, as this may be another feature of this emerging condition.