EVALI Masquerading as Cannabinoid Hyperemesis Syndrome

Abstract

In mid-2019, cases of acute eosinophilic pneumonia caused by the vaporization and inhalation of tetrahydrocannabinol (THC) containing products began to rapidly appear. E-cigarette or vaping product useassociated lung injury, or EVALI as it became known, was eventually linked to substances such as vitamin E used in illicit manufacture of THC containing vaping products. A previously healthy 20 year old male presented with complaints of worsening nausea, vomiting, abdominal pain, fevers, and dry cough of several months. Symptoms began 3 months prior with periods of intractable nausea and vomiting that lasted from 24 hours to 1 week without complete resolution. An extensive outpatient workup was completed by gastroenterology without definitive diagnosis, including endoscopy. The patient had attempted therapy with ondansetron, phenergan, metoclopromide, cannabidiol (CBD) gummy candies, vaporized CBD and THC without success. Physical exam was remarkable for nystagmus on far lateral gaze, prompting concern for a central cause of his persistent nausea and vomiting. Chest x-ray was unremarkable, and laboratory examination was remarkable for mild leukocytosis. Neurology was consulted and MRI brain was unremarkable. Seventy-two hours after admission, with supportive care, his nausea and vomiting had improved, but he developed new fever of 101.9°F. CT angiogram of the thorax revealed diffuse ground glass opacities with an upper lobe predominance and opacification in the lower lobes without pulmonary embolism. COVID-19 nasal swab was obtained, and treatment for community acquired pneumonia was started empirically. CRP was elevated to 34.9 mg/dl, urine L. pneumophila, S. pneumoniae, respiratory virus PCR panel, H. capsulatum, Aspergillus antigen, Fungitell assay, and COVID-19 PCR testing, with subsequent repeat, were negative. On the 4th day of admission, he became short of breath with increasingly worse cough leading to desaturation in the low 80%'s requiring 6 L oxygen via nasal cannula. Pulmonology was consulted, and given his THC exposure, negative laboratory testing and CT thorax appearance, a diagnosis of EVALI was made. Prednisone (0.5 mg/kg) was started, and over the next 72 hours, the patient's cough improved with continued supportive care. He was discharged to complete a 15 day prednisone taper. The rapid rise in cases lead to nationwide reporting of manufacturing processes and consumer awareness, which has subsequently lead to a decrease in the number of reported EVALI cases. Our patient's presentation with prolonged gastrointestinal distress left an initially broad differential and reminds us to discuss vaping of THC-containing products with all patients with vaping exposure.