key: cord-0831368-mhfyn0te
authors: Ahmed, Mohammad; Juarez, Matthew; Bangash, Bilal
title: A CASE OF E-CIGARETTE OR VAPING PRODUCT USE-ASSOCIATED LUNG INJURY CONFOUNDED BY RECENT COVID-19 INFECTION
date: 2021-10-31
journal: Chest
DOI: 10.1016/j.chest.2021.07.925
sha: 4e182d7f32176d046b886517a40be3255e21db5b
doc_id: 831368
cord_uid: mhfyn0te

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The E-cigarette, or vaping, associated lung injury (EVALI) phenomenon began in the US in 2019. Cases have since decreased but continue to occur. Diagnosis has been confounded by the Coronavirus disease 2019 (Covid-19) pandemic. We present a case of a young patient with EVALI, confounded by various factors including recent Covid-19.

A 33 year old man with a history of Covid-19 infection 1 month prior and e-cigarette (e-cig) with tetrahydrocannabinol (THC) use presented to the ED after being found in respiratory arrest. He had ingested opioid medication for acute back pain and consumed 5 alcoholic beverages 30 minutes prior to developing respiratory arrest. Respiratory arrest improved with naloxone, although he remained in respiratory failure requiring high-flow nasal cannula. Labs were notable for respiratory acidosis with hypoxemia. CTA thorax demonstrated moderate bilateral consolidations and ground glass opacities with subpleural sparing. He was begun on dexamethasone and broad-spectrum antibiotics. Throughout the remainder of his hospital stay, the patient's infectious work-up returned negative and oxygen was weaned without residual respiratory impairments.

DISCUSSION: EVALI has posed numerous diagnostic problems for clinicians. It most typically presents with nonspecific constitutional, respiratory, and gastrointestinal symptoms in young adults with a recent history of using e-cig products containing THC. Radiographic findings include nonspecific basilar-predominant consolidations and ground glass opacifications. The etiology is unclear, although mounting evidence points towards contamination with the thickening agent vitamin E acetate which potentially decreases the integrity of pulmonary surfactant and causes lung irritation. Covid-19 has further confounded the diagnostic process. Its pathophysiology involves the binding of virus to ACE2 receptors on human epithelial cells, subsequently inducing inflammation, tissue damage, and disordered cytokine release. Radiographic findings are nonspecific and can include diffuse infiltrates with or without ground glass opacifications. Although no pathognomonic findings distinguish EVALI from Covid-19, a thorough history is essential to determine recent e-cig with THC use. Our patient's respiratory failure was most likely multifactorial and caused predominantly by a combination of EVALI in the setting of concomitant opiate use and alcohol ingestion. His history of Covid-19 1-month prior likely predisposed him to developing EVALI due to residual systemic inflammation.

The Covid-19 pandemic has confounded the diagnosis of EVALI and underscores thorough history-taking to determine substance use. It is important to consider, however, that these conditions may not be mutually exclusive. Despite the ongoing pandemic, it is important to keep an index of suspicion for EVALI as a cause of acute lung injury. 

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