An Elusive Case of E-Cigarette, or Vaping, Product Use Associated Lung Injury (EVALI) Lacking Respiratory Symptoms

Abstract

Introduction: Electronic vaping-associated lung injury (EVALI), attributed to inhalation through E-cigarettes and other devices was first characterized in the US in July 2019. By February 2020, 2807 cases were reported. Patients often present with respiratory, gastrointestinal, and constitutional symptoms. The presence of EVALI without respiratory complaints is under-recognized, only reported three times in the literature thus far. Case: A 22-year-old female student presented with five days of fever, watery, nonmucoid, non-bloody diarrhea, nausea, 3-4 episodes of vomiting, and generalized weakness, without cough, dyspnea, chest or abdominal pain. Social history revealed vaping e-cigarettes containing nicotine and tetrahydrocannabinol for the past 3-4 years with increased use recently due to upcoming exams. She denied smoking traditional cigarettes, marijuana, or illicit drugs. A temperature of 101oF and 98% SaO2 were recorded. Physical examination was notable for bilateral diffuse crackles with a normal abdominal examination. Initial labs demonstrated a WBC of 14,600 without a shift and the remaining labs were within normal limits. Despite the absence of respiratory symptoms, her chest radiograph revealed bilateral multifocal airspace disease. Further investigation with Chest CT showed extensive multifocal bilateral infiltrates and predominantly peripheral ground-glass opacities. COVID-19 PCR was negative three times. Influenza A and B, RSV, mycoplasma, and legionella testing were negative. She was unable to provide sputum for culture. Stool cultures were negative and an abdominal and pelvic CT was normal. She denied any history of dietary intolerances, prior diarrhea, or chronic colitis. Empiric treatment for atypical community-acquired pneumonia with intravenous ceftriaxone and azithromycin was initiated, with little improvement over the subsequent 4 days. Lack of clinical effect with antibiotics prompted a suspicion for EVALI and intravenous methylprednisolone 1mg/kg every 8 hours was initiated. There was a significant improvement of her gastrointestinal and constitutional symptoms within 24 hours. After three days of IV steroids, she was discharged on an enteral taper. A repeat Chest CT scan 2 weeks later demonstrated complete resolution of the previously identified ground-glass opacities. Discussion: The use of E-cigarettes has grown by 900% between 2011 and 2019 among young adults but used by older individuals as well. This has contributed to the burgeoning EVALI epidemic. Although COVID has taken the centre stage while identifying diffuse interstitial lung abnormalities, there must be a high index of suspicion regarding the incidence of EVALI, especially in young patients, considering the varied presentations and the potential absence of respiratory symptoms.