"HIS-STORY": The Clinical Key Leading to a Diagnosis of EVALI

Introduction-We present the case of a young male with constitutional symptoms thought to be consistent with community-acquired or COVID-19 pneumonia, who was instead found to have a history of vaping tetrahydrocannabinol (THC) and was diagnosed with EVALI (E-cigarette, or Vaping, Product Use-Associated Lung Injury). Case Presentation-21-year-old male college student presented to the hospital in July 2020 with a 2-week history of abdominal pain, vomiting, diarrhea, headache and generalized myalgias. More recently, he had a fever and dry cough associated with worsening shortness of breath. In the hospital, the patient was initially requiring minimal oxygen and was febrile to 102°F. Physical exam was consistent with a young, diaphoretic male with tachypnea who had bilateral basilar crackles on auscultation of lungs. Bloodwork revealed a leukocytosis of 19.2k/mm3, ferritin of 1081ng/mL and a CRP of 64mg/dL. An initial chest x-ray was consistent with bilateral interstitial markings. 2 days later, he was admitted to the intensive care unit since he was requiring high-flow nasal cannula. A Computed Tomography (CT) of the chest (Figure 1A, 1B) showed extensive peribronchial groundglass opacity with subpleural sparing. Complete respiratory viral panel, COVID-19, Tuberculosis, HIV and tickborne illnesses testing were all negative. By this time, the patient had been treated with antibiotics for presumed community-acquired pneumonia. The pulmonary service was consulted, and detailed social history-taking revealed that the patient had started vaping THC obtained from a less well-known brand, shortly before the onset of his symptoms. A bronchoscopy was performed which revealed evidence of anthracotic pigment present in distal airways. Bronchoalveolar lavage (BAL) ultimately revealed no evidence of infection or malignancy and showed foamy macrophages. Based on his presentation, a diagnosis of EVALI was made and the patient was started on intravenous corticosteroids. During the next 3 days, the patient's fever defervesced and his inflammatory markers down-trended. He was discharged home on room air with a corticosteroid taper. Discussion-Targeted history taking which addressed the specifics of the 'off-brand' or counterfeit THC vaping brands was key in revealing the etiology of the patient's symptoms and allowed the initiation of the correct treatment in a timely manner. Vitamin-E acetate has emerged as a potential common exposure among affected patients who use a variety of counterfeit products. Clinicians should be well versed with asking specific questions focused on type, duration and brand of products when EVALI is suspected.