LEFT SIDE PREDOMINANT E-CIGARETTE OR VAPING USE-ASSOCIATED LUNG INJURY (EVALI): A CHALLENGING DIAGNOSIS OF EXCLUSION

SESSION TITLE: Signs and Symptoms of Chest Disease Case Report PostersSESSION TYPE: Case Report PostersPRESENTED ON: 10/19/2022 12:45 pm - 01:45 pmINTRODUCTION: Knowledge is lacking regarding the pathophysiology of E-cigarette, or vaping associated lung injury (EVALI). A diagnosis of exclusion with an unproven mechanism, EVALI presents with a characteristic history and clinical picture but with diverse imaging and histopathologic findings.CASE PRESENTATION: A 34-year-old male presented to the emergency department with five days of increasing shortness of breath, fatigue, fevers, left sided chest pain, productive cough, and episodes of profuse vomiting, leading to a concern for aspiration. The patient's history was notable for asthma and prior tobacco use. He continues to vape nicotine daily. He was placed on 2L nasal cannula. Chest CT demonstrated a diffuse, predominantly left sided ground glass opacities. He was started on empiric antibiotic therapy and admitted for a presumed diagnosis of multifocal pneumonia vs aspiration pneumonitis. However, there was no leukocytosis, his blood and sputum cultures were negative, and his autoimmune work up negative. The patient's clinical course did not improve with this treatment course and the Pulmonary service was consulted. Bronchioalveolar lavage did not reveal any infectious explanation and had a normal cell count and differential. Oil red O stain demonstrated numerous lipid-laden macrophages consistent with both EVALI and aspiration. No obvious fistula was noted on the bronchoscopy to explain left sided aspiration. Due to persisting symptoms after a week of antibiotics, he underwent a lung biopsy which showed scattered fibrin deposition within areas of organizing pneumonia and rare zones of hyaline membrane deposition, characteristic of prior reports associated with EVALI. The patient's condition improved with supportive care, and did not require steroids.DISCUSSION: This case highlights the challenges of EVALI work up and diagnosis, as the development of an evidence-based approach is ongoing [2] and it remains a diagnosis of exclusion [3]. Clinically, patients often present with fever, dyspnea, cough, and often emesis, in the context of recent vape use and in the absence of infectious or autoimmune findings. However, documented radiologic and histopathologic findings, while heterogenous in specific features, almost always present bilaterally. The highly unusual imaging findings further complicated the clinical picture, and a bronchoscopy and lung biopsy were required. While it is always crucial to rule out infection and other cardiopulmonary conditions, clinical judgement remains central to diagnosis of EVALI, given the consistency of exposure history and constellation of presenting symptoms. Further invasive workup including should be reserved for atypical cases [1].CONCLUSIONS: An evidence-based approach to EVALI remains nascent. Diagnosis is challenging due to the breadth radiographic and histopathological findings and relies on strong clinical decision making to pursue an appropriate workup.Reference #1: Aberegg SK, Maddock SD, Blagev DP, Callahan SJ. Diagnosis of EVALI: General Approach and the Role of Bronchoscopy. Chest. 2020 Aug;158(2):820-827.Reference #2: Kalininskiy A, Bach CT, Nacca NE, Ginsberg G, Marraffa J, Navarette KA, McGraw MD, Croft DP. E-cigarette, or vaping, product use associated lung injury (EVALI): case series and diagnostic approach. Lancet Respir Med. 2019 Dec;7(12):1017-1026.Reference #3: Kligerman S, Raptis C, Larsen B, Henry TS, Caporale A, Tazelaar H, Schiebler ML, Wehrli FW, Klein JS, Kanne J. Radiologic, Pathologic, Clinical, and Physiologic Findings of Electronic Cigarette or Vaping Product Use-associated Lung Injury (EVALI): Evolving Knowledge and Remaining Questions. Radiology. 2020 Mar;294(3):491-505.DISCLOSURES: No relevant relationships by Tyler BoydNo relevant relationships by Omar JaradatNo relevant relationships by tochukwu njepuomeNo relevant relationships by Shyam Shankar SESSION TITLE: Signs and Symptoms of Chest Disease Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Knowledge is lacking regarding the pathophysiology of E-cigarette, or vaping associated lung injury (EVALI). A diagnosis of exclusion with an unproven mechanism, EVALI presents with a characteristic history and clinical picture but with diverse imaging and histopathologic findings. CASE PRESENTATION: A 34-year-old male presented to the emergency department with five days of increasing shortness of breath, fatigue, fevers, left sided chest pain, productive cough, and episodes of profuse vomiting, leading to a concern for aspiration. The patient's history was notable for asthma and prior tobacco use. He continues to vape nicotine daily. He was placed on 2L nasal cannula. Chest CT demonstrated a diffuse, predominantly left sided ground glass opacities. He was started on empiric antibiotic therapy and admitted for a presumed diagnosis of multifocal pneumonia vs aspiration pneumonitis. However, there was no leukocytosis, his blood and sputum cultures were negative, and his autoimmune work up negative. The patient's clinical course did not improve with this treatment course and the Pulmonary service was consulted. Bronchioalveolar lavage did not reveal any infectious explanation and had a normal cell count and differential. Oil red O stain demonstrated numerous lipid-laden macrophages consistent with both EVALI and aspiration. No obvious fistula was noted on the bronchoscopy to explain left sided aspiration. Due to persisting symptoms after a week of antibiotics, he underwent a lung biopsy which showed scattered fibrin deposition within areas of organizing pneumonia and rare zones of hyaline membrane deposition, characteristic of prior reports associated with EVALI. The patient's condition improved with supportive care, and did not require steroids. DISCUSSION: This case highlights the challenges of EVALI work up and diagnosis, as the development of an evidence-based approach is ongoing [2] and it remains a diagnosis of exclusion [3]. Clinically, patients often present with fever, dyspnea, cough, and often emesis, in the context of recent vape use and in the absence of infectious or autoimmune findings. However, documented radiologic and histopathologic findings, while heterogenous in specific features, almost always present bilaterally. The highly unusual imaging findings further complicated the clinical picture, and a bronchoscopy and lung biopsy were required. While it is always crucial to rule out infection and other cardiopulmonary conditions, clinical judgement remains central to diagnosis of EVALI, given the consistency of exposure history and constellation of presenting symptoms. Further invasive workup including should be reserved for atypical cases [1]. CONCLUSIONS: An evidence-based approach to EVALI remains nascent. Diagnosis is challenging due to the breadth radiographic and histopathological findings and relies on strong clinical decision making to pursue an appropriate workup. Reference #1: Aberegg SK, Maddock SD, Blagev DP, Callahan SJ. Diagnosis of EVALI: General Approach and the Role of Bronchoscopy. Chest. 2020 Aug;158(2):820-827. Reference #2: Kalininskiy A, Bach CT, Nacca NE, Ginsberg G, Marraffa J, Navarette KA, McGraw MD, Croft DP. E-cigarette, or vaping, product use associated lung injury (EVALI): case series and diagnostic approach. Lancet Respir Med. 2019 Dec;7(12):1017-1026. Reference #3: Kligerman S, Raptis C, Larsen B, Henry TS, Caporale A, Tazelaar H, Schiebler ML, Wehrli FW, Klein JS, Kanne J. Radiologic, Pathologic, Clinical, and Physiologic Findings of Electronic Cigarette or Vaping Product Use-associated Lung Injury (EVALI): Evolving Knowledge and Remaining Questions. Radiology. 2020 Mar;294(3):491-505. DISCLOSURES: No relevant relationships by Tyler Boyd No relevant relationships by Omar Jaradat No relevant relationships by tochukwu njepuome No relevant relationships by Shyam Shankar