What About the First Public Health Crisis of 2019? EVALI in the Time of COVID

Abstract

Introduction: E-cigarette or Vaping Product Use Associated Lung Injury (EVALI) and Coronavirus Disease 2019 (COVID-19) are both relatively new disease processes which can cause acute respiratory failure. This report describes the case of a 17-year-old male with a history of vaping cannabis during the first wave of the COVID-19 pandemic in Michigan. Report: A previously healthy 17-year-old male presented with cough, shortness of breath, chest pain, fever, and hypoxia requiring 40L high flow nasal cannula (HFNC) and 100% FiO2 to maintain oxyhemoglobin saturations of 88%. He showed no tachypnea or retractions, mimicking the “happy hypoxia” reported in COVID-19 patients. His physical exam demonstrated inspiratory crackles and migratory diminished breath sounds. Chest x-ray showed mild peri-bronchial thickening, subtle right perihilar opacities, and hyperexpansion. Bloodwork showed a procalcitonin of 10 nanograms/milliliter, ESR of 10 millimeters/hour, and CRP of 3.5 milligrams/deciliter. Three prior SARS-CoV2 tests were negative, but given clinical suspicion, the patient was treated as a Patient Under Investigation (PUI) for COVID-19 for 48 hours and re-tested. Care was aligned with institutional COVID-19 guidelines to minimize aerosol-generating procedures;diagnostic bronchoscopy, positive pressure ventilation, and transport for chest CT were discouraged, especially as our patient was awake, interactive, and with gradually improving trajectory. Infection prevention guidelines prohibited our patient's parents from leaving his room for a private interview, but friends alerted them to a history of vaping cannabis, which our patient corroborated. He was transitioned towards supportive care for EVALIinduced bronchoconstriction and improved with beta agonists, systemic steroids, and HFNC. After his fourth negative SARS CoV2 test, the patient underwent a high-resolution chest CT, which showed diffuse ground-glass opacities with subpleural sparing. He was discharged after four days with Pediatric Pulmonology follow up. He was counseled against further e-cigarette or cigarette use. Discussion: This case illustrates challenges in the diagnosis of EVALI during the COVID-19 pandemic, particularly among adolescents. Both conditions present with acute respiratory failure absent another source. Both can have significant hypoxia, elevated inflammatory markers, and an ARDS phenotype. Both demonstrate ground-glass opacities on CT scan. Importantly, here are differences in the workup, management, and public health implications of EVALI and COVID-19. Both are reportable to the Department of Public Health and warrant intervention: Anti-vaping campaigns and restriction on access for EVALI, infection control and immunization programs for COVID-19. As the world endeavors to contain the COVID-19 pandemic through surveillance, treatment, and immunization, we also hope to regain momentum against EVALI.