Electronic-cigarette or vaping use-associated lung injury (EVALI) is an illness that requires further awareness for appropriate diagnosis and management. This series is a retrospective chart review of EVALI cases admitted from June to December 2020 at a large academic children’s hospital in New York.
Notably during this time, the coronavirus disease 2019 (COVID-19) global pandemic rendered the world under strict quarantine mandates. We discuss 7 patients, all of whom were seen in a clinic, urgent care, or emergency department before presentation to our hospital.
Patients presented with respiratory, gastroenterology, and constitutional complaints typically seen with EVALI and COVID-19. However, given their complex presentations in the setting of the COVID-19 pandemic, EVALI was not considered as pertinent history was not elicited.
With the COVID-19 pandemic as a setting for these cases, we emphasize the importance of eliciting a complete psychosocial history for all adolescents because without vaping disclosure, EVALI will go undiagnosed. It is also imperative to ensure consistent outpatient follow-up, although difficult because of limited access or hesitation and fear of acquiring COVID-19 in health care settings during the pandemic, and to stress vaping cessation, both of which are crucial in preventing further complications.
Alongside the emergence of electronic cigarettes (e-cigarettes) and vaping devices, there have been case reports and published guidelines regarding the recognition, diagnosis, and treatment of e-cigarette or vaping product-associated lung injury (EVALI).1–4 Product use skyrocketed more than 900% from 2011 to 2015, with almost 20% of high schoolers and 5% of middle schoolers reporting use.5 The latest data from the Center for Disease Control and Prevention (CDC) from February 2020 reports an EVALI caseload of 2800 cases and 68 deaths in the United States.6 In New York, as of March 2020, the reported total was 178 cases, with the highest concentration of cases in New York City and Nassau County.7
The type of device, frequency of use, and composition of e-liquid contribute to a wide range of presentations. The ingredients in e-liquids blunt the immune response associated with an increased risk for pulmonary infections.8,9 Vitamin E acetate has been identified in bronchoalveolar lavage of EVALI patients and is commonly found in THC-containing products with contaminants such as pesticides and heavy metals.10–14 Vitamin E acetate affects lung surfactant resulting in respiratory dysfunction.11–15 Patients with EVALI can present with gastrointestinal and constitutional complaints such as nausea, vomiting, diarrhea, and fever.1–4 Given the broad presentations of EVALI, increased awareness is necessary, because prompt treatment and immediate vaping cessation are critical to avoid long-term complications.
Similarly, coronavirus disease 2019 (COVID-19) presentations are broad and encompass cardio-respiratory, constitutional, and gastrointestinal complaints.16 With the health care system overwhelmed by the COVID-19 pandemic, we surmise it may be difficult to obtain a complete adolescent psychosocial history and nonspecific symptoms to COVID-19 rather than EVALI. There are growing concerns for the mental well-being of our adolescent population amid quarantine measures.17 With social isolation and decreased activity, some adolescents have developed poor coping strategies.18,19 On the other hand, as quarantine measures ease, more adolescents will be interacting with peers and increasing their access to vaping. As additional COVID-19 variants emerge and only 5% of adolescents are vaccinated, COVID-19 will remain prevalent.20 We, therefore, aim to present this case series of 7 patients to highlight the importance of maintaining a high index of suspicion for EVALI within the backdrop of the COVID-19 pandemic to prevent delayed diagnosis and treatment.
Methods
This case series is composed of 7 patients with EVALI admitted from June to December 2020. This timeframe was chosen to examine the impact of the COVID-19 surge in NYC on the diagnosis of EVALI and to characterize affected patients. Approval was obtained through the Northwell Health institutional review board. The patient cohort was determined from chart review of confirmed or suspected cases of EVALI seen by the pulmonary service because these patients, whether under the care of hospitalists of intensivists, require a mandatory pulmonary consult.
Results
All patients received PCR testing for COVID-19, and none underwent flexible bronchoscopy. Six were confirmed cases of EVALI, defined by the use of vaping within 90 days before symptom onset with pulmonary infiltrates in the absence of infection or other plausible causes.19 One was treated for as EVALI-concomitant respiratory infection, distinguished by published criteria.19 None of the patients tested positive for active COVID-19 infection by polymerase chain reaction (PCR) nor had evidence of previous infection.
Clinical Presentation, Testing, Imaging
Of the 7 patients, 4 presented to the emergency department (ED), 2 to their primary care clinic, and 1 to urgent care during the COVID-19 pandemic. Four patients presented with primary gastrointestinal complaints, and 2 presented with primary respiratory complaints. All patients exhibited tachypnea, and 5 patients were also hypoxic. The median duration of symptoms before presentation was 7 days. No vaping histories were elicited, disclosed, or documented at initial presentation. Of note, 1 patient was readmitted for EVALI having been admitted initially 1 year before. He was counseled on vaping cessation on his last admission but was lost to pulmonary clinic follow-up. He presented to an outlying hospital 6 months after discharge where he was initially treated for multisystem inflammatory disease in children (MIS-C) because of elevated inflammatory markers, despite negative COVID-19 testing and negative antibodies. After transfer to our hospital he was diagnosed with EVALI because he admitted to continued vaping.
Vaping history was elicited at our hospital with THC products being most frequently used. All patients admitted to vaping within 90 days before admission with all vaping up to 1 week before. Laboratory results for all patients were significant for elevated inflammatory markers, transaminitis, anemia, and leukocytosis. Table 1 reports patient demographics; clinical and laboratory data are shown in Tables 2 to 4. Imaging primarily revealed bilateral airspace disease with peripheral sparing, with 2 patients who had more prominent airspace disease at the bases. One patient had severe pneumomediastinum and subcutaneous emphysema (Fig 1). The readmission patient’s imaging demonstrated diffuse, bilateral airspace opacities with peripheral sparing (Fig 2), similar to his first hospitalization.
Coronal computed tomography (CT) slice of the chest shows diffuse ground glass opacities with peripheral sparing, with pneumomediastinum (arrow) and subcutaneous emphysema.
Coronal computed tomography (CT) slice of the chest shows diffuse ground glass opacities with peripheral sparing, with pneumomediastinum (arrow) and subcutaneous emphysema.
Coronal CT slice of the chest demonstrates diffuse airspace opacities with peripheral sparing. This image is from 1 patient’s second hospitalization for EVALI, showing remarkably similar findings when compared with his initial CT from his first hospitalization for EVALI.
Coronal CT slice of the chest demonstrates diffuse airspace opacities with peripheral sparing. This image is from 1 patient’s second hospitalization for EVALI, showing remarkably similar findings when compared with his initial CT from his first hospitalization for EVALI.
Patient Demographics, Medical History, and Substance Use Characterization
| Variable | Number of Patients (%) |
|---|---|
| Average age, y (range) | 16 (16–17) |
| Sex | |
| Male | 5 (71) |
| Female | 2 (29) |
| Race | |
| White | 6 (86) |
| Other or multiracial | 1 (14) |
| Medical Histories | |
| History of asthma | 2 (29) |
| Reported psychiatric conditiona | 5 (71) |
| Vaping use history in the 90 d before admission | |
| THC-only vaping | 3 (43) |
| THC and nicotine vaping | 3 (43) |
| Nicotine-only vaping | 1b (14) |
| Variable | Number of Patients (%) |
|---|---|
| Average age, y (range) | 16 (16–17) |
| Sex | |
| Male | 5 (71) |
| Female | 2 (29) |
| Race | |
| White | 6 (86) |
| Other or multiracial | 1 (14) |
| Medical Histories | |
| History of asthma | 2 (29) |
| Reported psychiatric conditiona | 5 (71) |
| Vaping use history in the 90 d before admission | |
| THC-only vaping | 3 (43) |
| THC and nicotine vaping | 3 (43) |
| Nicotine-only vaping | 1b (14) |
THC, tetrahydrocannabinol.
Depression, anxiety, and/or attention deficit/hyperactivity disorder.
Patient found to be THC positive but denied THC vaping.
Initial Vital Signs
| Initial Vital Signs | Number of Patients (%) |
|---|---|
| Temperature ≥ 38°C | 4 (57) |
| Heart rate ≥ 100 beats/min | 4 (57) |
| Respiratory rate ≥ 20 breaths/min | 7 (100) |
| Hypotension, SBP <90 mmHg or DBP <60 mmHg | 3 (43) |
| Oxygen Saturation ≤92% in room air | 5 (71) |
| Initial Vital Signs | Number of Patients (%) |
|---|---|
| Temperature ≥ 38°C | 4 (57) |
| Heart rate ≥ 100 beats/min | 4 (57) |
| Respiratory rate ≥ 20 breaths/min | 7 (100) |
| Hypotension, SBP <90 mmHg or DBP <60 mmHg | 3 (43) |
| Oxygen Saturation ≤92% in room air | 5 (71) |
DBP, diastolic blood pressure; SBP, systolic blood pressure.
Clinical Characteristics of Hospitalizations
| Clinical Characteristics | Number of Patients (range or %) |
|---|---|
| Confirmed EVALI case | 6 (85.7) |
| Probable EVALI case | 1 (14) |
| Median number of provider interactions before diagnosisa | 2 (1–5) |
| Location of initial presentation | |
| ED of outside hospital | 4 (57.1) |
| Urgent care | 1 (14) |
| Clinic | 2 (28.5) |
| Primary reported chief complaint | |
| Gastrointestinal symptoms | 3 (42.8) |
| Respiratory symptoms | 2 (28.5) |
| Combination | 2 (28.5) |
| Required ICU, % total | 3 (42.8) |
| Respiratory support | |
| Required nasal cannula or venturi mask | 3 (42.8) |
| Required positive pressure ventilation | 2 (28.5) |
| No respiratory support | 2 (28.5) |
| Median total days of hospitalization, d | 9 (3–11) |
| Received antibiotics | 7 (100) |
| Treated with systemic steroids and discharged with taper | 7 (100) |
| Clinical Characteristics | Number of Patients (range or %) |
|---|---|
| Confirmed EVALI case | 6 (85.7) |
| Probable EVALI case | 1 (14) |
| Median number of provider interactions before diagnosisa | 2 (1–5) |
| Location of initial presentation | |
| ED of outside hospital | 4 (57.1) |
| Urgent care | 1 (14) |
| Clinic | 2 (28.5) |
| Primary reported chief complaint | |
| Gastrointestinal symptoms | 3 (42.8) |
| Respiratory symptoms | 2 (28.5) |
| Combination | 2 (28.5) |
| Required ICU, % total | 3 (42.8) |
| Respiratory support | |
| Required nasal cannula or venturi mask | 3 (42.8) |
| Required positive pressure ventilation | 2 (28.5) |
| No respiratory support | 2 (28.5) |
| Median total days of hospitalization, d | 9 (3–11) |
| Received antibiotics | 7 (100) |
| Treated with systemic steroids and discharged with taper | 7 (100) |
Clinic, urgent care, or emergency department visits and/or admission to outside institution.
Median Peak Laboratory Values
| Laboratory Value | Median (Range) | Reference Units |
|---|---|---|
| WBC count (initial) | 16.9 (6–23.6) | 3.8–10.5 K/uL |
| Hemoglobin | 13.0 (10.1–15.8) | 10.0–17.0 g/dL |
| Hematocrit | 39.0 (28–47.9) | 39.0% to 50.0% |
| Platelet count | 541.0 (204–1555) | 150–400 K/uL |
| C-Reactive protein (n = 6) | 241.6 (107.7–453.6) | <5.0 mg/L |
| ESR (n = 3) | 100 (77–132) | 0–20 mm/hr |
| Lactate dehydrogenase (n = 6) | 488.5 (311–983) | 135–255 U/L |
| AST (n = 6) | 92 (30–259) | 4–40 u/L |
| ALT (n = 6) | 50 (25–486) | 4–41 u/L |
| 2 wk postdischarge DLCO (n = 4) | 68.5 (67–91) | % of reference |
| Laboratory Value | Median (Range) | Reference Units |
|---|---|---|
| WBC count (initial) | 16.9 (6–23.6) | 3.8–10.5 K/uL |
| Hemoglobin | 13.0 (10.1–15.8) | 10.0–17.0 g/dL |
| Hematocrit | 39.0 (28–47.9) | 39.0% to 50.0% |
| Platelet count | 541.0 (204–1555) | 150–400 K/uL |
| C-Reactive protein (n = 6) | 241.6 (107.7–453.6) | <5.0 mg/L |
| ESR (n = 3) | 100 (77–132) | 0–20 mm/hr |
| Lactate dehydrogenase (n = 6) | 488.5 (311–983) | 135–255 U/L |
| AST (n = 6) | 92 (30–259) | 4–40 u/L |
| ALT (n = 6) | 50 (25–486) | 4–41 u/L |
| 2 wk postdischarge DLCO (n = 4) | 68.5 (67–91) | % of reference |
ALT, alanine aminotransferase; AST, aspartate aminotransferase; DLCO, diffusing capacity of carbon monoxide; ESR, erythrocyte sedimentation rate; WBC, white blood cell count.
Management, Outcomes, Postdischarge Follow-Up
Of the 5 patients who were hypoxic, 3 needed supplemental oxygen and 2 required noninvasive ventilation. Three patients required admission to the ICU. All patients initially received empirical antibiotics, which were discontinued except for 1 patient for concomitant Mycoplasma infection. Five patients received intravenous methylprednisolone, 1 mg/kg per dose, with a maximum of 60 mg per dose, every 8 to 12 hours. Two patients, whose presentations were less severe, were managed with oral prednisone, 1 mg/kg daily, maximum dose of 60 mg. All patients were discharged with oral prednisone tapers as recommended by Kalininskiy, et al.21
The median duration of hospitalization was 9 days, with a range of 3 to 11 days. All patients and families received information for vaping cessation and extensive counseling regarding the risks of vaping. Four patients followed with our pulmonary clinic within 2 weeks of discharge; 3 of whom had decreased diffusing capacity; 1 additionally showed a reversible obstructive defect consistent with airway reactivity. Unfortunately, only 1 returned for additional follow-up with normalization of lung function in 1 month.
Discussion
Diagnosis of EVALI is challenging, especially when respiratory symptoms are not the predominant complaint. Respiratory, gastrointestinal, and constitutional symptoms seen with EVALI are also seen with COVID-19.22 The complex presentations during the pandemic and lack of disclosure or ascertainment of vaping history obfuscated diagnosis of EVALI and may have resulted in illness significant enough to require ICU admission, use of noninvasive positive pressure ventilation, and longer duration of hospitalization as compared to the national average of 7 days for EVALI admission, relative to the median in our series of 9 days.23,24
As mentioned, a major factor contributing to a missed diagnosis of EVALI diagnosis was a failure to obtain a substance use history, which should be standard history-taking for all adolescents. Even as patients were hesitant to disclose such information, the responsible physician should discuss the importance of this information. Given that some patients presented to adult urgent care or EDs, there may be a lack of familiarity with typical adolescent psychosocial screenings, thus missing important aspects of a history.25 Additionally, an adult urgent care or ER would be overwhelmed with the volume and acuity of COVID-19 patients to be able to take time to conduct a psychosocial screen. EVALI may be missed with bias introduced by COVID-19.
Additionally, poor compliance with outpatient follow-up underscores the difficulty associated with acknowledging and understanding the severity of this disease and importance of vaping cessation. Long-term complications of EVALI include obstructive lung diseases such as asthma, interstitial lung disease, and even lung cancer.12,26,27 Since our patients presented during a global pandemic, we invoke lack of follow-up was partly because of fewer available appointments and fear of contracting COVID-19 in the health care setting. In the hospital, efforts should be geared toward pulmonary follow-up and vaping cessation, especially given that with discontinuation, lung function can return to normal within a 6-month period.21,28 Communication between hospitalists and primary care physicians are crucial in coordinating follow-ups, discussing patients’ psychosocial challenges, and managing vaping cessation plans.29–31
This series is limited by the small sample size seen at a single center, therefore making it difficult to generalize the findings. Additionally, all patients initially presented to another acute care setting, limiting information collected as this was a retrospective chart review. We were only able to ascertain follow-up with our pulmonary clinic, and information regarding pediatrician follow-up was not readily available as not all pediatric practices employed the hospital’s electronic medical records. Nevertheless, these cases illustrate complex presentations and common clinical findings of adolescents with EVALI.
Conclusions
These cases and their varied presentations illustrate the challenge of diagnosing EVALI, especially when vaping use is not elicited. Physicians can expect reluctance to disclose this information but should discuss its importance.25 We also highlight the challenges with the diagnosis in the setting of the COVID-19 pandemic. An overlapping presentation with bias toward COVID-19, limited access to care, as well as fear to seek treatment during the pandemic were contributory to a missed, if not, delayed diagnosis. Further, there is a need for increased awareness of EVALI and its long-term consequences.32 As COVID-19 continues to be prevalent with new variants and suboptimal vaccination rates, EVALI must remain in our differential diagnosis. Clinicians must continue to engage in efforts to protect this vulnerable pediatric population.
FUNDING: No external funding.
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no conflicts of interest to disclose.
Drs Rai, Hormozdyaran, and Burns conceptualized and designed the structure of this case series, collected data, drafted the initial manuscript, and reviewed and revised the manuscript; Dr Quizon conceptualized the structure of this case series, reviewed and revised the manuscript, and provided important academic and intellectual content; Dr Amodio conceptualized the structure of this case series, provided images, and wrote accompanying captions; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
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