key: cord-0810216-n5par08q
authors: Jagroop, Nia; Megally, Michael
title: LOOKING AT THE GROUND GLASS THROUGH COVID-19 COLORED GLASSES: A CASE OF EVALI AMIDST THE COVID-19 PANDEMIC
date: 2021-10-31
journal: Chest
DOI: 10.1016/j.chest.2021.07.1702
sha: f4543d3c1d29778ff2b58690a12a8afaca18c74f
doc_id: 810216
cord_uid: n5par08q

nan

INTRODUCTION: Electronic Vape Associated Lung Injury (EVALI) is respiratory failure with symptom onset within 90 days of electronic cigarette use, pulmonary infiltrates on imaging, absence of infection, and lack of an alternate cause. Typical imaging shows bilateral ground glass opacities. Its presentation may be mistaken for infectious pneumonia such as SARS-COV-19. Prompt recognition is the key to initiating treatment and patient recovery.

CASE PRESENTATION: At the height of the COVID-19 pandemic, a healthy 28-year-old male presented to the emergency department with worsening shortness of breath and dry cough. He was sent home on azithromycin for pneumonia. COVID-19 PCR was negative. Due to worsening symptoms, he returned two days later. Vitals revealed hypoxia and auscultation of the chest yielded diffuse bilateral rales. Computed Tomography of the chest showed extensive bilateral ground glass opacities. Significant labs included C-reactive protein 289.23 MG/L, lactate dehydrogenase of 344 U/L, procalcitonin of .028 NG/M and white blood cells 12.06 K/CMM. COVID-19 PCR testing was again negative. During admission patient was tested twice more for COVID-19 with negative results. Respiratory Viral Panel, Legionella, Mycoplasma and Streptococcus testing were negative as well. Pulmonary medicine was consulted for COVID-19 pneumonia. Upon further history taking the patient admitted to twice daily use of tetrahydrocannabinol (THC) vape and EVALI was diagnosed. Treatment included IV steroids as well as Ceftriaxone and Azithromycin for possible atypical pneumonia. Hypoxia quickly resolved within 48 hours and the patient was discharged home. Outpatient the patient had complete resolution of symptoms and imaging findings.

The liquid in vaping cartridges contains nicotine, THC and/or cannabinoids (CBD). Solvent agents like vitamin E acetate (VEA) and medium-chain triglycerides (MCT) act as vehicles to carry the active ingredients. Upon aerosolization, VEA and MCT may interact with phospholipids and surfactants of the epithelial lining causing barrier dysfunction. VEA and MCT stimulate cellular toxicity via oxidative and inflammatory responses in epithelial cells and monocytes. This can be evidenced by lipid laden macrophages on bronchioalveolar lavage. EVALI manifests as a dry cough, dyspnea and ground glass opacities on imaging as seen in our aforementioned patient. Treatment is with glucocorticoids with taper over five to ten days for moderate to severe cases and empiric treatment of community acquired pneumonia with antibiotics.

In the hazy setting of the COVID-19 pandemic, other causes of acute respiratory failure like EVALI remain present. It is of utmost importance to keep non COVID-19 causes of acute respiratory failure in mind and to encourage cessation of the pulmonary toxic agents known to worsen outcomes pulmonary predominant diseases.

Pulmonary toxicity and inflammatory response OF Vape Cartridges Containing Medium-Chain Triglycerides oil and Vitamin E ACETATE: Implications in the pathogenesis of EVALI

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