E-cigarette, or vaping, product use-associated lung injury in adolescents during COVID-19 pandemic

Rationale: E-cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI) cases share similar symptomatology to coronavirus disease-19 (COVID-19) making the diagnosis challenging when adolescents present with fever and cough during the COVID-19 pandemic. Methods: In this retrospective chart analysis, we reviewed the clinical, laboratory, and radiographic presentations of teenagers diagnosed with EVALI at UCD Children's Hospital, between February and December 2020. Results: A total of 10 teenagers were hospitalized for EVALI during the study period. The average age was 16.1±0.8 years;40% of patients were female. 40% were Hispanic;40% were Caucasian. Common presenting symptoms included fever (90%), cough (90%), and abdominal symptoms such as nausea, vomiting, and abdominal pain (90%). The laboratory results showed an elevated white blood cell count (18.19±4.1) with neutrophil predominance (88.02±11.3), and elevated C-reactive protein levels (23.5±13.6). Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing was done in 9/10 patients and all were negative. Chest radiographs were reported as bilateral opacities (70%), normal (20%), and pneumomediastinum (10% of the cases). Chest computerized tomography, done for 8/10 patients, showed bilateral ground glass opacities in 7/8 patients (Figure 1). With high index of suspicion for EVALI, careful and repeat questioning revealed frequent use of tetrahydrocannabinol vaping products in all cases. The average length of stay was 5±2.7 days;70% needed admission in the pediatric intensive care unit and one patient required intubation. 90% of patients were treated with corticosteroids with a response to treatment within 48 hours. 60% had follow-up in pulmonary clinic, at which point all patients had complete resolution of symptoms. Discussion: Our study shows the similarities in clinical, laboratory, and radiographic findings between EVALI and COVID-19. EVALI cases have decreased since legalization of marijuana, mostly due to reduced use of vitamin E acetate, an adulterant in street products and a common culprit in EVALI cases. However, most of our teenagers obtain vaping products from informal sources and therefore outbreaks continue. There may also be potential for increased EVALI cases secondary to COVID-19 social distancing restrictions. When adolescents present with COVID-19 symptoms, providers should elicit pertinent vaping history. SARS-CoV-2 as well as other appropriate diagnostic work-up should be pursued since EVALI is a diagnosis of exclusion. Early initiation of steroids in EVALI can shorten duration of illness. Appropriate vaping cessation counseling and close outpatient monitoring are needed to reduce the risk of recurrence. 3 of 10 cases were previously published as a case report: https://pubmed.ncbi.nlm.nih.gov/33194204/.