EVALI Masquerading as COVID-19: A Case Report

Introduction: The CDC first defined e-cigarette or vaping product use-associated lung injury (EVALI) as the presence of pulmonary infiltrates on plain film chest radiograph or ground glass opacities on chest CT in September 2019. However since the COVID-19 pandemic, the same radiological appearance have become synonymous with COVID-19 pneumonia. We present a case of a patient who was mistakenly presumed to have COVID-19 and was later found to be a case of EVALI. Case Presentation: 33 year old obese Caucasian male with 15 pack year smoking history and no past medical history presented with one month of worsening exertional dyspnea associated with cough, sore throat, subjective chills, and diaphoresis. He was admitted to the COVID-19 unit due to hypoxemia requiring 3 L/min of oxygen and chest CT scan with contrast showing bilateral ground glass opacities with mosaic attenuation. COVID-19 reverse transcriptase RNA PCR test was negative twice. Labs showed leukocytosis of 12,700 with 74.4% neutrophils and 15.7% lymphocytes, normal procalcitonin of 0.09 ng/mL, and normal BNP of 83 pg/mL. Pulmonary was consulted and after detailed history was obtained, the patient reported vaping nicotine three weeks prior to admission. Respiratory viral panel, including influenza A and B, urine legionella and pneumococcal antigens were all negative. He underwent inpatient flexible fiberoptic bronchoscopy with right upper lobe bronchoalveolar lavage (BAL) and right upper lobe transbronchial biopsy. BAL cell count showed 89% alveolar macrophages including numerous lipid laden macrophages and 6% eosinophils with transbronchial biopsy showing benign respiratory epithelium with unremarkable alveolated lung parenchyma. Diagnosis of EVALI was made, and patient clinically improved after starting on prednisone. He was discharged on steroid taper and will be followed in the pulmonary clinic with repeat CT imaging to check for resolution. Discussion: With the emergence of COVID-19 pandemic there is a bias in diagnosing all ground glass opacities on CT chest in the setting of hypoxemia as COVID-19 pneumonia. However, as per CDC guidelines, our patient met the criteria for EVALI with recent history of vaping within 90 days, typical radiological findings, and infectious causes ruled out. This diagnosis was made more robust by the findings of lipid laden macrophages on BAL. Our case emphasizes the importance of preventing anchoring bias during this COVID-19 pandemic by taking time to obtain a more thorough history and including other causes of lung injury, such as, EVALI in our differential diagnoses.