key: cord-0748071-5l3suf6d
authors: Pitlick, Mitchell M.; Lang, Daenielle K.; Meehan, Anne M.; McCoy, Christopher P.
title: EVALI: A Mimicker of COVID-19
date: 2021-03-29
journal: Mayo Clin Proc Innov Qual Outcomes
DOI: 10.1016/j.mayocpiqo.2021.03.002
sha: af96a7de35f64fb8b88e9cc6c36e442aef86e867
doc_id: 748071
cord_uid: 5l3suf6d

E-cigarette or vaping product use associated lung injury (EVALI) is a respiratory illness that has significant overlap with the symptoms of COVID-19. In the current pandemic, diagnosis of EVALI may be delayed due to anchoring bias when patients present with symptoms consistent with COVID-19. We present three cases of patients who were hospitalized with a presumed diagnosis of COVID-19, but were later diagnosed with EVALI.

bilateral patchy basilar opacities. He had two negative SARS-CoV-2 nasopharyngeal tests around 89 that time. He was given a dose of ceftriaxone and then completed a 5 day course of Augmentin 90 and azithromycin for presumed community acquired pneumonia. His symptoms worsened 91 however and he presented 10 days after symptom onset. 92

He was now hypoxic requiring 2L O2 via nasal cannula. He was febrile to 38.2° C, tachycardic 93 with a heart rate of 110 beats per minute, and tachypneic with a respiratory rate of 30 breaths 94 per minute. Lab work showed a worsening leukocytosis, neutrophilia, lymphopenia, elevated 95 CRP and elevated D-dimer (Table 1) . Chest CT showed diffuse mid-lung predominant ill-defined 96 groundglass opacities with interlobular septal thickening (Image 1). He was admitted to the 97 hospital, given IV fluids, and started on levofloxacin. A repeat SARS-CoV-2 test and respiratory 98 pathogen panel (both nasopharyngeal swabs) were negative, as was SARS-CoV-2 serology. His 99 respiratory status worsened, and he was transferred to the ICU where high flow nasal cannula 100 55% FiO2 at 45 L/min was started. Given the lack of improvement on antibiotics, repeated 101 negative SARS-CoV-2 testing, and history of vaping, he was treated for EVALI with prednisone. 102

He had rapid improvement within the first day of treatment and completed a 4 day course of 103 prednisone 40 to 80 mg daily. He was discharged on room air on hospital day 5. and azithromycin for possible community-acquired bacterial pneumonia. SARS-CoV-2 PCR and a 111 respiratory pathogen panel obtained via nasopharyngeal swab were negative. His respiratory 112 status worsened, and he required 6L O2 to maintain saturations. After further discussion, 113 patient reported vaping with cannabis oil several times daily in the weeks prior to admission. 114

Repeat SARS-CoV-2 testing via both a nasopharyngeal swab and sputum sample were negative, 115 as was serology testing. CT scan showed extensive bilateral ground-glass opacities in a 116 predominantly central distribution with associated interlobular septal thickening (Image 2). 117 Given significant hypoxia and diagnostic uncertainty, he underwent bronchoscopy. A thorough 118 infectious and autoimmune panel, including his fourth SARS-CoV-2 PCR, on bronchoalveolar 119 lavage specimens was negative. A cell count showed 47% alveolar macrophages, 36% 120 neutrophils, 12% lymphocytes and pigment-laden macrophages. At this point, a presumptive 121 diagnosis of EVALI was made. He remained intubated after bronchoscopy but was quickly 122 extubated. He required high flow nasal cannula but was able to be weaned to room air without 123 steroid treatment. He was discharged to home on hospital day 11. 124

Case 3: 125 7 basilar interstitial infiltrates. A CT of the chest showed diffuse bilateral groundglass opacities 133 with a peripheral predominance (Image 3). Lab work showed a mild leukocytosis with a 134 lymphopenia and an elevated CRP and D-dimer (Table 1) . He was admitted to the hospital, 135

given IV fluids, and started on ceftriaxone and azithromycin for community acquired 136 pneumonia. He remained persistently febrile with elevated inflammatory markers. He had two 137 additional SARS-CoV-2 nasopharyngeal swabs that were negative, as was serology testing. 138

Given his lack of improvement and significant vaping history, he was treated for EVALI with 125 139 mg of methylprednisolone for 3 days. He had prompt resolution of his fevers, improvement in 140 his cough, and reduction of his inflammatory markers. He was discharged to home on hospital 141 day 5. We presented three cases of a febrile respiratory illness initially thought to be due to COVID-19. 187 COVID-19 symptoms are non-specific and can be seen in a variety of other infectious and non-188 infectious conditions. There is substantial overlap in the presenting signs and symptoms of 189 EVALI and COVID-19, and it should be emphasized that constitutional symptoms are as common 190 a feature of EVALI as they are of COVID-19. 3-4, 6-8 This highlights the importance of a thorough 191 history. All patients presenting with these symptoms should be asked about substance use. 192

While EVALI is a diagnosis of exclusion, identification of vaping or e-cigarette use in the history 193 alters the differential diagnosis and subsequent evaluation in treatment. Aside from history, 194 use of chest CT is also important to differentiate these two entities. However, while CT imaging 195 can be useful, it is not recommended as a first line diagnostic test. 14 In addition to an accurate 196 history, for COVID-19 the gold standard of diagnosis remains the NAAT, the sensitivity and 197 specificity of which is high in ideal conditions. [15] [16] However, the test performance is dependent 198 on both specimen quality and duration of illness at time of testing, with false negative rates 199 ranging from <5% to 40% depending on the specimen source. [15] [16] Even when diagnostic 200 uncertainty exists, the use of CT should not be pursued without first weighing the potential 201 risks of exposure to other medical personnel with potential benefits of the CT itself. This report 202 highlights both the importance of an accurate history, as well as the risk of diagnostic error and 203 bias in the setting of a global pandemic. Given the similar signs and symptoms, most clinicians 204 will consider COVID-19 first, rather than another cause. This is appropriate during a pandemic, 205 but it is also imperative to consider alternate diagnoses if repeated testing is negative. 206

Clinicians must be cognizant of the potential for cognitive bias, including anchoring and 207 availability bias. Anchoring occurs when clinicians put significant emphasis on features of a 208 patient's initial presentation that may lead to dismissal of information learned later in the 209 clinical course. 17 Availability bias refers to a clinician's judgement of how likely a diagnosis is 210 based on how easily an example of that diagnosis is mentally generated. 17 Recent or emotional 211 events are often deemed more probable to recur again due to the clarity with which they are 212 recalled. 17 This is especially true during the COVID-19 pandemic. While COVID-19 is a condition 213 

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Epub ahead of print

Detection of SARS-CoV-2 in Different Types of Clinical 269

ACR Recommendations for the use of Chest Radiography 271 and Computed Tomography (CT) for Suspected COVID-19 Infection

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