E-cigarette or vaping product use associated lung injury, (EVALI) - A diagnosis of exclusion

Abstract

Inhalation of aerosolized products generated by different electronic devices is called vaping. E-cigarettes or Vaping product use Associated Lung Injury (EVALI) outbreak peaked in August–September 2019 and gradually declined. EVALI remains a diagnosis of exclusion which presents as an acute lung injury in the vaping population. Vitamin E acetate and its products are implicated as one of the cytotoxic agents causing airway centered pneumonitis. Lipid laden macrophages are found in samples of BAL fluid but their role in cytopathology of the disease remains unclear. We present a 57 years old man who came to the emergency department at Monmouth Medical Center, New Jersey in fall, 2019. Reportedly he has been vaping THC about 100g every day for past three days. At initial presentation, he had fever, shortness of breath and hypoxia requiring supplemental oxygen. He was empirically treated with levofloxacin 500 mg for five days without a significant improvement in his symptoms. Non-contrast chest CT scan showed bilateral ground-glass opacities, indicative of diffuse alveolar damage. He underwent flexible bronchoscopy to rule out infective pneumonia followed by auto-immune work-up that was non-conclusive. He was given 1 mg/kg methylprednisolone with a quick taper of oral steroids leading to the resolution of symptoms. At six months follow-up, imaging showed near resolution of ground-glass opacities.

Cardiorespiratory and Immunologic Effects of Electronic Cigarettes

“…The e-cigarette-induced changes in lipid metabolism of macrophages in mice are particularly interesting because similar lipid-laden macrophages have also been observed in humans who use e-cigarettes, particularly in individuals with e-cigarette-associated pneumonia [ 101 , 102 ]. Similar lipid-laden macrophages have also been detected in the BAL fluid of EVALI patients [ 103 ]. Although such lipid-laden macrophages have also been found in the lung of smokers, in e-cigarette users, these macrophages are associated with inflammatory cytokines such as IL-4 and IL-10, but not with smoking-related cytokines [ 104 ], suggesting that the pathophysiological changes induced by e-cigarettes in macrophages may be different in nature from that afflicted by combustible cigarettes.…”

ASRA Pain Medicine consensus guidelines on the management of the perioperative patient on cannabis and cannabinoids

“…The immediate effects of oral or inhaled THC induces bronchodilation both in healthy subjects and those with asthma,220 221 but aerosolized THC or cannabis smoking may also result in an irritation of the airways and bronchoconstriction in some individuals with reactive airway disease 222. Evidence of harm is limited to small case series and case reports 212 223–229. A small clinical trial and several case reports of patients with acute shortness of breath and hemoptysis within hours of cannabis use have been published 230–233.…”

Acute Respiratory Distress Syndrome During the COVID-19 Era

“…E-cigarette or vaping product use–associated lung injury is a diagnosis of exclusion 6 in a patient with acute lung injury and e-cigarette or vaping product use before symptom onset 7 . A recent study of the CT scans of patients with EVALI showed 96% had ground-glass opacities, 42% had consolidation, and 29% demonstrated smooth interlobular septal thickening 8 .…”