ABSTRACT
INTRODUCTION: E-cigarette or vaping product use associated lung injury (EVALI) is a recently described acute or subacute respiratory illness due to inhalation of toxic e-cigarette ingredients. Symptoms can include shortness of breath, cough, fever, chills, and gastrointestinal symptoms. It is a diagnosis of exclusion made in patients with history of vaping. DESCRIPTION: A 25-year-old male with history of untreated hypertension, childhood asthma, and regular vaping presented to the emergency department with 5 days of dyspnea, fever, nausea, vomiting, and diarrhea. He had a fever to 101.2 F and hypoxia requiring 2 L/min supplemental oxygen by nasal cannula. He had leukocytosis to 21/mm3. Chest CT revealed multifocal ground glass consolidations. His presentation was highly concerning for COVID-19, and he was designated a person under investigation (PUI) with agreement by the infectious disease consultation. PCR test for COVID-19 was negative. He was started on ceftriaxone and azithromycin for empiric treatment of community acquired pneumonia. However, three days later his oxygen requirement increased to high flow nasal cannula. HIV, urine legionella and streptococcal antigens, respiratory viral panel, and blood cultures were negative. COVID-19 testing was repeated twice due to suspicion of false negative and was negative, but he was started on dexamethasone per COVID-19 protocols as he continued to be a PUI. Additionally, he was encouraged to self-prone and use incentive spirometry. Hypoxia initially started to improve, but worsened again along with a recurrent fever, prompting initiation of a second course of antibiotics. Ultimately, it was concluded that there was no active infectious etiology for his hypoxic respiratory failure and he likely has EVALI. He was weaned off of oxygen after 2 weeks of hospitalization and was discharged with follow-up. DISCUSSION: This case demonstrates the susceptibility of physicians to the availability heuristic when developing a differential diagnosis during the COVID-19 pandemic. Particularly, the presentation of EVALI is remarkably similar to that of COVID-19. One of the few distinguishing features is leukocytosis in EVALI, whereas COVID-19 typically presents with leukopenia. It is important to maintain a broad differential including EVALI and assess patients for history of vaping.