Electronic cigarette or vaping product use–associated lung injury (EVALI) is a newly emerging diagnosis in the United States, yet the incidence has surged greatly in the past year. With the trend of using electronic cigarettes (e-cigarettes) and vaping rising at an alarming rate among teenagers, many are resorting to friends, illicit drug dealers, and other informal sources to obtain their e-cigarettes, which is greatly contributing to the national outbreak of EVALI. The incidence of adolescents presenting with the constellation of respiratory, gastrointestinal, and constitutional symptoms characteristic of EVALI has been widely reported within the nation. We present one such case of an adolescent boy with a 2-year history of daily vaping who presented with nausea, vomiting, weight loss, and fever but lacked the respiratory symptoms that have been reported in the majority of EVALI cases reported thus far. Computed tomography scan of the abdomen and pelvis revealed an incidental finding of lung pathology characteristic of EVALI, prompting further workup and diagnosis of EVALI. In this case, it is demonstrated that the presentation of EVALI can be variable and is still poorly defined. The rising morbidity and mortality from EVALI reveal the importance of considering EVALI in all patients with a history of vaping or e-cigarette use, regardless of the presence or absence of respiratory symptoms.

In recent years, electronic cigarette (e-cigarette) use (also known as vaporizer pens) has gained popularity at an alarming rate. In particular, they are being used by teenagers, presumably because of their ease of use, a perception of decreased harm compared with traditional cigarette use,1  and targeted advertising via social media.2  Government and health care officials have voiced concerned over the use of these devices because there are little to no data on the health implications of these devices and because the use of any form of nicotine is unsafe for adolescents.3 

Recently, several deaths and hundreds of cases of e-cigarette or vaping product use–associated lung injury (EVALI) have been reported, and these numbers continue to rise. Nearly one-fifth of these patients are younger than 18 years.4  An exact causative agent has yet to be identified. An association has been made between EVALI and use of the vaporizers for tetrahydrocannabinol-containing products, although some cases have been reported with isolated use of nicotine-containing products.4  Most notably, tetrahydrocannabinol products obtained from informal sources such as friends and illicit drug dealers have played a large role in the national outbreak of EVALI.5  Patients may present with a variety of pulmonary, cardiac, gastrointestinal, and other systemic complaints, such as dyspnea, cough, chest pain, dizziness, or nausea and vomiting. As the number of cases multiplies, clinicians have begun to have a higher index of suspicion for EVALI in the setting of pulmonary complaints given a history of vaporizer pen use.

This is a case of a teenage boy who came to the hospital with 3 months of vomiting and weight loss as well as recent-onset headache and fever, with a history of vaping but without any pulmonary complaints, discovered incidentally on workup to have EVALI.

A 16-year-old boy with no significant past medical history presented to our hospital with a 25-pound weight loss over a 3-month period in the setting of persistent postprandial nausea, decreased appetite, and occasional nonbloody and nonbilious emesis. The patient reported a 2-year history of daily vaping, using nicotine-based products multiple times a day and tetrahydrocannabinol-containing cartridges at night over the preceding few months. The patient reported that he had ceased vaping ∼2 weeks before his presentation with temporary resolution of his nausea and vomiting as well as improvement in his appetite. However, in the 3 days before his presentation, he developed daily fever, headache, nausea, nonbloody and nonbilious emesis, and one episode of nonbloody diarrhea. He denied any history of cough, dyspnea, chest pain, or exertional intolerance. Two days before his hospital admission, he presented to our emergency department for the aforementioned symptoms. At that time, a basic metabolic panel and chest radiograph were obtained, both of which were normal. Results from a urine drug screen were positive for marijuana metabolites and negative for all other drugs. Ondansetron and a normal saline bolus were administered, and he was discharged after tolerating oral intake. The patient followed-up with his primary care provider, who obtained laboratory studies that revealed a complete blood count notable for a white blood cell count of 12 700 cells/µL and 91% neutrophils and a C-reactive protein (CRP) elevated to 29.7 mg/dL. His primary care provider subsequently referred him back to our hospital’s emergency department for further evaluation, given his persistent symptoms and these abnormal laboratory results.

This patient’s vital signs on admission were notable for a temperature of 39.2°C, blood pressure of 102/55 mm Hg, heart rate of 108 beats per minute, respiratory rate of 20, peripheral capillary oxygen concentration of 95% to 99% on room air, and BMI of 20.97. On examination, he was without acute distress but appeared thin. His lungs were clear to auscultation bilaterally with no signs of labored breathing. His cardiac examination was benign. His abdomen was soft, nontender, nondistended, and with no organomegaly or masses. He had no appreciable lymphadenopathy. The rest of his examination was unremarkable. His initial laboratory studies on admission included a complete blood count that was notable for leukocytosis to 11 800 cells/µL with 96% neutrophils, a comprehensive metabolic panel with mild hyponatremia to 133 mmol/L but otherwise unremarkable, and unremarkable γ-glutamyl transferase, amylase, lipase, uric acid, and creatine phosphokinase. His lactate dehydrogenase was elevated to 1028 U/L. His erythrocyte sedimentation rate was elevated to 46 mm/hour, and his CRP was elevated to 22.0 mg/dL.

Additional workup included a fecal calprotectin test, celiac panel, and thyroid studies that were within normal limits. A computed tomography (CT) abdomen and pelvis scan without contrast did not reveal any significant intra-abdominal pathology but did reveal extensive opacities in the dependent aspect of both lower lung lobes and dependent aspects of the right middle lobe and lingula, incompletely evaluated on the study. This prompted a CT of the chest without contrast that showed diffuse, patchy areas of ground glass opacification and interlobular septal thickening throughout both lungs with a lower lobe predominance relative sparing of the periphery. There were also scattered linear areas of subsegmental atelectasis or scarring in the lower lobes, right middle lobe, and left upper lobe. These findings were interpreted to most likely represent EVALI on the basis of the clinical history. Pulmonary function tests were administered and were consistent with restrictive and mixed lung disease and diffusion at the lower limit of normal. A 6-minute walk test revealed desaturations. A respiratory panel did not detect any pathogens, and sputum culture grew normal respiratory flora. The result of urine Legionella antigen testing was negative. The patient was started on intravenous methylprednisolone, 1 mg/kg per dose every 6 hours for 3 days. After completion of this 3-day course of high-dose corticosteroids, repeat 6-minute walk test had normalized, and his erythrocyte sedimentation rate and CRP had decreased to 40 mm/hour and 0.66 mg/dL.

Throughout his 7-day hospital stay, the patient had no chest pain, cough, or respiratory distress and remained without hypoxemia except for during the initial 6-minute walk test. He remained stable and was treated with as-needed oral acetaminophen and ibuprofen and intravenous ondansetron for fever and nausea, respectively. The patient’s fever, nausea, and vomiting resolved after initiation of corticosteroids. He was ultimately discharged on oral prednisone and lansoprazole. Follow-up one week after discharge revealed normalization of his pulmonary function testing and of his serum inflammatory markers. Follow-up CT of the lungs at 2 weeks after discharge was completely normalized.

Current literature shows that gastrointestinal symptoms often precede the respiratory symptoms in EVALI.6  In a recent study in which researchers analyzed the clinical presentation of 53 cases of pulmonary illness related to e-cigarette (also called vaping) use in Illinois and Wisconsin, 98% of cases had respiratory symptoms at hospital presentation, with 87% having shortness of breath, 83% having cough, and 55% having chest pain.7  Furthermore, 70% had gastrointestinal symptoms, including nausea, vomiting, diarrhea, and abdominal pain, and 100% of patients had constitutional symptoms, with the most common being subjective fever (81%).7  In current literature, among reported cases of patients who required hospitalization, there have only been 2 patients who lacked respiratory symptoms. One of these patients had a resting oxygen saturation of 91%, which warranted further workup and eventually led to the diagnosis of EVALI.7  The second patient had no respiratory complaints, but CT findings suggestive of EVALI were incidentally discovered. He was given antibiotics and discharged from the hospital with no formal treatment of this condition.8 

Our patient presented with gastrointestinal and constitutional symptoms, including nausea, vomiting, abdominal pain, weight loss, and fever. Notably, initial workup (physical examination, oxygen saturation, chest radiograph) was unremarkable for pulmonary pathologies, and he denied respiratory symptoms for the entirety of his hospital stay. However, this patient suffered significant morbidity from his weight loss and gastrointestinal symptoms, all of which continued to worsen after he quit vaping weeks before his presentation. By the end of his stay, he reported improved mood; resolution of his nausea, emesis, and fever; and marked improvement in his appetite. This mirrored his improving inflammatory markers and pulmonary function tests. It is possible that timely diagnosis and treatment of this patient expedited resolution of his symptoms.

This patient’s case appears to be a less typical presentation of EVALI, specifically because of a lack of pulmonary complaints. Alternatively, it is possible that he presented early in the course of his illness, before pulmonary symptoms could manifest. Regardless, appropriate treatment vastly improved his symptoms, which had not improved from his claimed vaping cessation 2 weeks earlier. However, it is challenging to know when to include this condition in the differential diagnosis because presenting symptoms and laboratory markers are nonspecific. Additionally, there are no data on the effects of early intervention and little knowledge on the best form of treatment.

With new cases emerging at a rapid rate and a limited understanding of the disease process and long-term sequelae, EVALI is a nationwide health concern. As more cases present themselves, we will be better able to characterize the disease presentation and best mode of intervention. Currently, the diagnosis of EVALI is gaining widespread recognition in society with reports centered on the drastic respiratory effects in affected patients. However, it is crucial that practitioners inquire about vaping usage in all patients presenting with profound constitutional or gastrointestinal symptoms. Medical professionals need to be suspicious of EVALI in any patient with a history of vaping to minimize chances of missing or misdiagnosing unique presentations of EVALI, such as was presented by our patient with an absence of respiratory symptoms.

Ms Matta was involved in data collection and patient care, drafted the initial manuscript, and reviewed and revised the manuscript; Ms Hamati drafted the initial manuscript and reviewed and revised the manuscript; Drs Unno and Fox coordinated and supervised data collection and patient care and critically reviewed the manuscript for important intellectual content; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

     
  • CRP

    C-reactive protein

  •  
  • CT

    computed tomography

  •  
  • e-cigarette

    electronic cigarette

  •  
  • EVALI

    e-cigarette or vaping product use–associated lung injury

1
Johnson
AC
,
Mays
D
,
Hawkins
KB
,
Denzel
M
,
Tercyak
KP
.
A qualitative study of adolescent perceptions of electronic cigarettes and their marketing: implications for prevention and policy
.
Child Health Care
.
2017
;
46
(
4
):
379
392
2
Huang
J
,
Duan
Z
,
Kwok
J
, et al
.
Vaping versus JUULing: how the extraordinary growth and marketing of JUUL transformed the US retail e-cigarette market
.
Tob Control
.
2019
;
28
(
2
):
146
151
3
US Department of Health and Human Services
.
E-Cigarette Use Among Youth and Young Adults. A Report of the Surgeon General
.
Atlanta, GA
:
US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health
;
2016
4
CDC
.
Outbreak of lung injury associated with the use of e-cigarette, or vaping, products.
2019
. Available at: https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html. Accessed September 25, 2019
5
CDC
.
New CDC report provides first analysis of lung injury deaths associated with use of e-cigarette, or vaping, products.
2019
. Available at: https://www.cdc.gov/media/releases/2019/p1028-first-analysis-lung-injury-deaths.html. Accessed September 25, 2019
6
Farkas
J.
Vaping associated pulmonary injury (VAPI). Available at: https://emcrit.org/ibcc/vaping-associated-pulmonary-injury/. Accessed September 25, 2019
7
Layden
JE
,
Ghinai
I
,
Pray
I
, et al
.
Pulmonary illness related to e-cigarette use in Illinois and Wisconsin - final report
.
N Engl J Med
.
2020
;
382
(
10
):
903
916
8
Maddock
SD
,
Cirulis
MM
,
Callahan
SJ
, et al
.
Pulmonary lipid-laden macrophages and vaping
.
N Engl J Med
.
2019
;
381
(
15
):
1488
1489

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.