Case Presentation: A 21 year old man with no past medical history presented to the emergency department with shortness of breath, vague upper midline abdominal pain, nausea, vomiting and watery, non-bloody diarrhea for four days. He denied any sick contacts or recent travel. Patient admits to smoking JUUL e-cigarettes for 3 years. Vital signs were within normal limits. CT abdominal imaging showed areas of patchy and ground glass attenuation with intralobular septal thickening suggestive of pulmonary vascular congestion with superimposed pneumonia. Lab work during was significant for ESR: 114mm/h, Procalcitonin 7.10 ng/ml and a white blood cell count of 17.9 K/uL . Physical exam was remarkable for bibasilar crackles. Patient was admitted for suspected pneumonia and started on broad spectrum antibiotics. Infectious work up was negative and patient continued to spike fevers despite antibiotics. Antibiotics were discontinued and patient was started on prednisone to treat suspected vaping-induced lung injury. Patient showed remarkable improvement on prednisone and was discharged to home.
Discussion: As of the first week of November, there have been around 2,051 confirmed and probable cases of E-cigarette, or vaping product use associated lung injury (EVALI) nationally with 39 deaths being reported. Both nicotine and cannabinoid containing products have been associated with these negative outcomes. Patients with EVALI present with respiratory, gastrointestinal and constitutional symptoms. Radiographic imaging typically demonstrates bilateral lower lobe ground-glass opacities with subpleural sparing. Occasionally, bronchoscopy has yielded lipid-laden macrophages. Early pulmonary and toxicology consultations as well as notification to the local Poison Control Center should be done. There is no standardized treatment for EVALI currently, but the following should be considered: (1) oxygen/ventilator support as indicated (2) empiric antibiotic coverage until infectious etiologies are ruled out (3) systemic corticosteroids, especially if no clinical improvement antibiotics and oxygen support. Decisions to perform bronchoscopy and lung biopsy should be made on a case-by-case basis.
Conclusions: EVALI is a rapidly emerging and mystifying health illness that has necessitated careful mindfulness and analysis. In New York, the majority of patients implicated have been under the age of 25 years old. In addition, nearly half of these patients have required intubation sending a strong message to hospitalists that a comprehensive history, timely diagnosis and treatment and an overall sense of hypervigilance is paramount. Patients should be strongly advised not to resume use of these products and will need close outpatient pulmonary surveillance to assess for long-lasting lung injury.