EVALI Presenting as a Lung Mass: A Diagnostic Challenge in a Young Adult

Abstract Introduction: Vaping, the use of E-cigarettes, involves heating and aerosolizing liquids for inhalation. These widely accessible devices have been increasingly linked to E-cigarette or vaping product use-associated lung injury (EVALI). Radiological findings of EVALI often include basilar-predominant consolidation and ground-glass opacity sparing the subpleural space. We present a unique case of a young patient with hemoptysis and a lung mass, which was ultimately diagnosed as EVALI after extensive workup. Case presentation: 24-year-old male with a history of exercise-induced asthma and vaping was transferred to a tertiary hospital secondary to massive hemoptysis. He had previously been treated with antibiotics for a 3-week history of hemoptysis, chest pain, cough, and night sweats. Lab workup demonstrated peripheral eosinophilia with elevated C-reactive protein and positive Aspergillus fumigatus IgE tests. A computed tomography scan revealed a large necrotic mass in the posterior right upper lobe with a feeding bronchial artery. The patient underwent a right upper lobe bronchial artery embolization to temporize ongoing hemoptysis. Antifungal therapy was initiated due to suspicion of aspergilloma. The patient then underwent bronchoscopy and endobronchial ultrasound with transbronchial needle aspiration (TBNA). Bronchoscopy showed external compression of the posterior right upper lobe segment. Pathology reports for bronchial washings and TBNA were negative for malignancy or organisms. Secondary to ongoing hemoptysis despite embolization and lack of significant improvement on imaging despite maximal medical therapy, the patient underwent a right upper lobectomy for definitive treatment of his hemoptysis. Pathology confirmed diffuse lung injury with organizing pneumonia and destruction of the bronchial tree, consistent with vaping-associated lung injury. Discussion: The pathogenesis of EVALI usually involves more than one mechanism of injury. Patients typically present with respiratory symptoms such as shortness of breath, cough, chest pain, and, rarely, hemoptysis. Laboratory workup is usually aimed at excluding other causes of lung injury. A study by Khanijo et al. showed that inflammatory markers can be elevated in patients with EVALI. EVALI has been associated with various radiographic patterns, such as hypersensitivity pneumonitis, diffuse alveolar hemorrhage, acute eosinophilic pneumonia, organizing pneumonia, and giant cell interstitial pneumonia. There are still no specific treatments targeted towards EVALI other than supportive care. Conclusion: Upon reviewing the literature, this is the first reported case of EVALI presenting as a lung mass causing extra-bronchial obstruction. Maintaining a high suspicion index for EVALI in patients presenting with respiratory symptoms and suspicious imaging findings is crucial, especially after more common differential diagnoses have been excluded.