ABSTRACT
Introduction: Electronic cigarettes and vaping associated lung injury (EVALI) is a new and emerging disease in the recent years. The patients who vape have Valsalva maneuver due to forceful exhalation from coughing which increases their risk for spontaneous pneumomediastinum (SPM). We present a case of 18 year-old man who has significant history of vaping and presents with SPM. Case Presentation: 18 Year old man with no medical history presented with cough, wheezing and shortness of breath for three weeks. He complained of pleuritic chest pain especially with coughing. He denied any fever, chills, nausea, vomiting or abdominal pain. He denied COVID-19 exposure or sick contacts. In the ER his Spo2 was 88% on ambient air so he was placed on O2 via nonrebreather mask with Spo2 of 94%. He denied smoking but endorsed to extensive daily vaping which resulted in severe coughing spasms. Complete blood count (CBC) showed leukocytosis of 19.2 K/UL. His COVID PCR was negative and COVID IgG was non-reactive and urine toxicology screen was negative for any illicit substances. CXR showed multiple bilateral reticular opacities and CT Chest showed multiple bilateral discrete consolidation in the central portion of both lungs (Fig. 1) and significant pneumomediastinum (PM). PM was thought to be secondary to coughing. He was started on methylprednisone 40 mg Q12hrs and oxygen therapy was continued with the goal to keep SPo2 >90%. He was taken off oxygen after 48 hours steroid treatment. His repeat imaging showed significant improvement of PM and patient was discharged with follow up. Discussion: The incidence of EVALI has increased especially among teenagers. Some of the known complications associated with vaping are atelectasis and pneumonia but PM is rare. The mechanism of PM can be explained by two hypotheses: 1. intrathoracic pressure from forceful inhalation during vaping leading to compensatory physiological exhalation against closed glottis resulting in alveolar damage. 2. Forceful inhalation through narrow lumen of vaping devise leading to Mullen's mechanism causing alveolar damage. This alveolar rupture leads air to dissect along peribronchovascular interstitial sheaths, visceral pleura, and into mediastinum (Macklin's effect) [1]. PM is usually treated with supportive without any significant adverse effects. From literature review only few cases have been reported describing EVALI related penumomediastim but physicians should be aware of the potential complications to educate their patients.