E-Cigarette or Vaping-Product Associated Lung Injury Complicated by Spontaneous Pneumothoraces in the Setting of COVID-19 Pandemic

Introduction: Electronic-cigarette or vaping-product associated lung injury (EVALI) was first identified in August 2019, when U.S. public health officials noted a clinical syndrome of acute respiratory failure and systemic inflammation associated with the use of aerosolized nicotine and cannabinoids. The presence of lipid-laden macrophages on bronchiolar lavage is a specific but not sensitive histological finding of EVALI, which is often a diagnosis of exclusion. In 2020, the first cases of COVID-19, caused by SARS-CoV2 virus, were seen in the U.S. Both COVID-19 and EVALI can affect previously healthy individuals, manifesting with severe hypoxemia and systemic inflammation, posing diagnostic challenges in distinguishing the two syndromes. Secondary spontaneous pneumothorax is a well-described complication of COVID-19 yet is only rarely associated with EVALI, with only one published case report of EVALI complicated by pneumothorax. Here, we report a case of a 34-year-old man presenting with hypoxemic respiratory failure complicated by pneumothorax, initially thought to be from COVID-19 pneumonia, found ultimately to have EVALI associated diffuse alveolar damage. Case: In April 2020, a 34-year-old man presented with one week of myalgia, shortness of breath, and a reduced exercise tolerance. Social history was notable for extensive vaping. His exam was notable for hypoxemia requiring nonrebreather. Testing showed elevated inflammatory markers and diffuse bilateral opacities on chest radiography. Nasopharyngeal PCR was negative for SARS-CoV2. CT chest revealed dense consolidation with ground grass opacities and air bronchograms. Rheumatologic and infectious workup was unremarkable. Despite six negative SARS-CoV2 tests, he was treated for COVID-19 with empiric steroids and antibiotics for community-acquired pneumonia. On hospital day 3, he developed a right-sided pneumothorax requiring chest tube. On hospital day 12, he developed a left-sided pneumothorax and a second chest tube was placed. A presumptive diagnosis of pneumonitis and diffuse alveolar damage secondary to EVALI was made. Given non-healing bilateral pneumothoraces, on hospital day 32, he underwent chemical pleurodesis with doxycycline which was complicated by ARDS. He was intubated, suffered a PEA arrest from refractory hypoxemia, and emergently cannulated to VV ECMO. A head CT demonstrated diffuse cerebral edema suggestive of anoxic brain injury. After extensive goals of care discussions, care was withdrawn and the patient passed away. Discussion: EVALI, similar to COVID-19, is syndrome of severe acute hypoxemia and systemic inflammation. Both conditions have similar radiographic findings with ground glass opacities indicative of alveolar damage, histological findings of tracheobronchitis and diffuse alveolar damage, and can lead to secondary spontaneous pneumothoraces.