Noxious Inhalation Lung Injury in the Setting of E-cigarette/Vaping Use

Abstract Introduction: E-cigarette and vaping product use associated Lung injury (EVALI) carries a potential for increased mortality particularly given the spectrum of clinicopathological findings in EVALI that mirror other common pulmonary diseases. EVALI being a diagnosis of exclusion portends delays in prompt diagnosis and appropriate management of this condition. Additionally, limited research and unclear management guidelines add to the complexity of managing EVALI. This case reports serves to draw attention to the importance for enhanced standardized guidelines, better regulatory framework, and future research in this field. Case Report: A 35-year-old man with a past medical history of OSA (not on CPAP), IV-heroine drug use (drug-free for 8 years and on Suboxone), Chronic Hepatitis C infection (not on any medications), current cigarette smoker with vaping for over 15 years and cholecystectomy presented to the Emergency Department (ED) with worsening dyspnea and tactile fevers for less a day with an episode of non-bloody vomiting, chronic vague, diffuse abdominal discomfort, and recent exposure to sick contacts. Vitals signs revealed a low-grade fever, tachycardia, tachypnea, O2 saturation (SpO2) of 87% on room air. Mild abdominal retractions and diffuse expiratory wheezes were noted on physical exam. Initial investigation demonstrated leukocytosis of 12.5 x103 K/uL and elevations in procalcitonin (2.78 ng/mL), C-reactive protein (97.7 mg/L) and lactate (2.4 – 4.0 mmol/L). All other infectious, autoimmune and vasculitic workup were negative. CT of the chest revealed symmetric ground-glass opacities bilaterally with pleural sparing and air bronchograms (Fig 1). No significant EKG changes noted. The patient was started on 2L of oxygen via nasal cannula, given Ceftriaxone, Azithromycin, Methylprednisolone and Duo-Nebulizers. He exhibited a brisk response to steroid therapy and empiric antibiotics and was discharged on a steroid taper a few days later with outpatient pulmonology follow up recommendations. Discussion: Establishing a diagnosis of EVALI remains a diagnosis of exclusion as there are no tests or markers available for detection. Future research prospects are currently oriented around identifying exposure-related and disease-related biomarkers to further characterize the pathogenesis and pathophysiology of EVALI. In essence, this case report highlights a critical respiratory syndrome underscored by its recent and rapid emergence in the clinical setting which necessitates further research as diagnostic molecular markers and long-term health outcomes of EVALI remain unknown.