Lung injury associated with an e-cigarette (vaping) use during the COVID-19 pandemic

In recent years, the excessive use of electronic cigarettes (e-cigarettes), and vaping, as a re-placement for traditional tobacco cigarettes, have highlighted potential health risks for users. One such risk is the development of "electronic cigarette (vaping) product use-associated lung injury" (EVALI). This type of lung injury has an unclear cause that may be related to the various components found in e-cigarette fluids. The Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection (coronavirus disease . 2019 or COVID-19) may worsen EVALI symptoms in individuals with both conditions. This could be due to the increased oxidative stress and inflammation caused by e-cigarette use, as re-search shows increased levels of reactive oxygen species (ROS) and decreased glutathione. In this paper, we present two critical cases of COVID-19 patients with a history of chronic e-cigarette smoking and describe their clinical progression during hospitalization. The findings suggest that their prolonged use of e-cigarettes may have sig-nificantly impacted the severity of the disease.Copyright © 2023, The Indonesian Foundation of Critical Care Medicine. All rights reserved.

Prospectively Assessed Long-Term Outcomes of Patients with E-Cigarette- or Vaping-associated Lung Injury.

Rationale: E-cigarette- or vaping-associated lung injury (EVALI) was first identified in 2019. The long-term respiratory, cognitive, mood disorder, and vaping behavior outcomes of patients with EVALI remain unknown. Objectives: To determine the long-term respiratory, cognitive, mood disorder, and vaping behavior outcomes of patients with EVALI. Methods: We prospectively enrolled patients with EVALI from two health systems. We assessed outcomes at 1 year after onset of EVALI using validated instruments measuring cognitive function, depression, anxiety, post-traumatic stress, respiratory disability, coronavirus disease (COVID-19) infection, pulmonary function, and vaping behaviors. We used multivariable regression to identify risk factors of post-EVALI vaping behaviors and to identify whether admission to the intensive care unit (ICU) was associated with cognitive, respiratory, or mood symptoms. Results: Seventy-three patients completed 12-month follow-up. Most patients were male (66.7%), young (mean age, 31 ± 11 yr), and White (85%) and did not need admission to the ICU (59%). At 12 months, 39% (25 of 64) had cognitive impairment, whereas 48% (30 of 62) reported respiratory limitations. Mood disorders were common, with 59% (38 of 64) reporting anxiety and/or depression and 62% (39 of 63) having post-traumatic stress. Four (6.4%) of 64 reported a history of COVID-19 infection. Despite the history of EVALI, many people continued to vape. Only 38% (24 of 64) reported quitting all vaping and smoking behaviors. Younger age was associated with reduced vaping behavior after EVALI (odds ratio, 0.93; P = 0.02). ICU admission was not associated with cognitive impairment, dyspnea, or mood symptoms. Conclusions: Patients with EVALI, despite their youth, commonly have significant long-term respiratory disability; cognitive impairment; symptoms of depression, anxiety, post-traumatic stress; and persistent vaping.

A COVID-19 MIMICRY MYSTERY

SESSION TITLE: Signs and Symptoms of Chest Disease Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Vaping products have been rapidly gaining popularity, with studies showing increasing use, even among school-going children and adolescents. E-cigarette or Vaping Associated Lung Injury (EVALI) is defined as respiratory failure within 90 days of e-cigarette use with pulmonary infiltrates on imaging, in the absence of infectious or alternative causes of respiratory failure.[1] Vitamin E acetate, a thickening agent in THC containing e-cigarettes, is thought to be the main causative agent of EVALI and has been found in the bronchoalveolar lavage samples in almost all cases of EVALI.[2] However, diagnosing EVALI in this era of COVID -19 is a challenge due to striking similarities in clinical symptoms and imaging findings. CASE PRESENTATION: A 32-year-old male with anxiety and polysubstance abuse, presented with headache, cough, low-grade fevers and chills of 1 week. In the ED, he was febrile to 102 F and hypoxic to 89% on room air and was started on 3 liters of oxygen. Labs showed leukocytosis and elevated inflammatory markers. Urine toxicology was positive for THC. Chest X-ray showed bilateral interstitial opacities. CT angio of the chest showed bilateral ground glass opacities. Despite 2 negative PCR tests, suspicion for COVID was high and the patient was initially started on dexamethasone and other supplements, along with antibiotic coverage for a possible bacterial etiology. Despite this, respiratory symptoms and hypoxia continued to worsen. Infectious work up including blood, sputum cultures with AFB staining, urine streptococcus and legionella tested negative. The patient however now revealed the regular use of THC containing vape and procuring the THC oil from a new street vendor. This prompted us to suspect vaping induced chemical pneumonitis. He was restarted on steroid therapy with methylprednisolone and within 1 week, had symptomatic improvement and resolution of hypoxia. The patient was eventually discharged on prednisone taper over 7-10 days. DISCUSSION: Our patient was initially treated for COVID pneumonia despite repeated negative PCR tests, as findings were suggestive of SARS-COV-2 infection. Fortunately, the patient eventually revealed about regular use of THC-oil vapes, making us consider a diagnosis of vaping induced chemical pneumonitis. The mainstay of treatment is steroid therapy and cessation of e-cigarette use. The severity of the pandemic has led to a low threshold for suspecting COVID, causing increased anchoring and availability bias, and potentially under-diagnosing conditions like EVALI which resemble COVID infection.[3] CONCLUSIONS: While it is important to have a low threshold for suspecting COVID-19, considering other mimics of COVID is prudent for providing treatment in an appropriate and timely manner. Detailed inquiry of e-cigarette use, particularly THC-oil containing vapes, duration of use and source of procurement, goes a long way in diagnosing of EVALI. Reference #1: EVALI and the Pulmonary Toxicity of Electronic Cigarettes: A Review Lydia Winnicka, MD and Mangalore Amith Shenoy, MD PMCID: PMC7351931 PMID: 32246394 Reference #2: Clinical presentation, treatment, and short-term outcomes of lung injury associated with e-cigarettes or vaping: a prospective observational cohort study Denitza P Blagev 1, Dixie Harris 2, Angela C Dunn 3, David W Guidry 2, Colin K Grissom 4, Michael J Lanspa 5 PMID: 31711629 DOI: 10.1016/S0140-6736(19)32679-0 Reference #3: EVALI: A Mimicker of COVID-19 Mitchell M. Pitlick, MD,a Daenielle K. Lang, MD,a Anne M. Meehan, MBBCh, PhD,b and Christopher P. McCoy, MDb, PMCID: PMC8006188 PMID: 33817560 DISCLOSURES: No relevant relationships by Kaushik Darbha No relevant relationships by Rashmikant Doshi No relevant relationships by Ishan Sahu No relevant relationships by sara samad

E-CIGARETTE OR VAPING USE-ASSOCIATED LUNG INJURY (EVALI): EFFECTS OF VAPING OR COVID-19?

SESSION TITLE: Critical Care in Chest Infections Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: EVALI is an acute lung injury that occurs due to the use of e-cigarettes or vaporizer products that usually contain THC or nicotine. There was an outbreak of EVALI in 2019. This is a diagnosis of exclusion with foamy macrophages with pneumocyte vacuolization being the best diagnostic clues. (1) Vitamin E acetate laced products seem to be the causing factor. CASE PRESENTATION: A 34-year-old female presented to the emergency department due to increasing shortness of breath, fever, pleuritic chest pain, cough, and headaches for the last 9 days. Two days prior she presented to urgent care where she was given an albuterol inhaler and azithromycin. At arrival, the patient was found to have tachycardia with a rate of 120-130, afebrile, SpO2 at 96% on room air, BP at 100/59. Her initial workup was grossly normal except for an elevated WBC and elevated D-Dimer. Chest X-ray revealed opacities in the lower lungs consistent with pneumonia. CTA of the chest revealed patchy pulmonary opacities consistent with COVID pneumonia. She took three separate SARS-CoV-2 PCR tests which all came back negative. The patient underwent a large workup which included infectious disease, pulmonology, and cardiology consults. She was treated with broad-spectrum antibiotics for the presumed diagnosis of pneumonia but her condition quickly deteriorated, eventually requiring 6L of O2 via nasal cannula. Screening for a large array of bacteria, fungus, and viruses all resulted negative. Upon further discussion with the patient, she admitted to smoking a THC vaporizer every night for the last seven months and that she had recently purchased a new fluid for her THC vaporizer through the internet. Bronchoscopy was also acquired but did not show any specific findings, including being negative for eosinophils. Discontinuation of antibiotics and initiation of IV steroids treatment provided rapid improvement of the patient's condition. Based on her history of THC vaping, the clinical presentation of fever, hypoxia, her chest x-ray, and chest CT showing extensive lung infiltrates, infections were ruled out and the most likely diagnosis of EVALI was made which responded well to steroids. DISCUSSION: COVID and EVALI initially can present similarly as respiratory problems, fever, and the need for oxygen. It is important to gather history on the patient as a vaping history is needed to suspect EVALI as imaging can show a wide range from ground-glass opacities to acute hypersensitivity pneumonitis. (2) CONCLUSIONS: There are some distinguishing features of EVALI from COVID one being in EVALI there is a large increase in the white count and lastly the response to steroids is the key (2). Steroids are the primary care for someone with EVALI with most patients recovering in 1-3 days with the use of steroids. (2) Reference #1: Bierwirth, A., Orellana, G., Milazzo, E. and Hamdan, A., 2020. TETRAHYDROCANNABINOL VAPING-ASSOCIATED LUNG INJURY (EVALI): A US EPIDEMIC?. Chestnet Journal. Reference #2: MacMurdo, M., Lin, C., Saeedan, M., Doxtader, E., Mukhopadhyay, S., Arrossi, V., Reynolds, J., Ghosh, S. and Choi, H., 2020. e-Cigarette or Vaping Product Use-Associated Lung Injury. Chestnet Journal. DISCLOSURES: No relevant relationships by Narden Gorgy No relevant relationships by Matheus Moreira Sanches Peraci No relevant relationships by George Walbridge No relevant relationships by John Zakhary

E-cigarette or Vaping Product Use Associated Lung Injury (EVALI) in Teenager After Reported COVID-19 Infection

Introduction: E-cigarette or vaping product use associated lung injury (EVALI) is a relatively new pulmonary syndrome linked to e-cigarette consumption. As of February 18th, 2020, a total of 2,807 hospitalized EVALI cases have been reported to the CDC. Among hospitalized EVALI cases, 15% (421 patients) were under the age of 18. Case Description: Patient is a 17-year-old previously healthy male who presented to the ED for a 3-day history of fever, progressively worsening nausea and vomiting, anorexia, dry cough, and night sweats. PMH was significant for COVID-19 infection in April 2021 and he was fully vaccinated for COVID-19 as of May 2021. Patient also noted 10 lbs. unintentional weight loss in the last month. Patient denied substance use or sexual activity. Family history was unremarkable. In the ED the patient was febrile and mildly tachycardic. Physical exam was grossly unremarkable including a normal lung exam. Relevant labs revealed a leukocytosis, hyponatremia, elevated ESR and CRP. SARS-COVID-2 PCR negative, SARS-COVID-2 IgG S1/S2 Spike protein positive, nucleocapsid negative. CXR, ECG, and RUQ U/S were unremarkable. Patient was subsequently admitted to the inpatient pediatric service for further management. During hospitalization the patient reported increased shortness of breath and pleuritic chest pain with SaO2 down to 86% on room air requiring supplemental oxygen. New social history obtained without family present revealed heavy vaping of nicotine and THC 'most days' for the past 3 years. Pediatric pulmonology was consulted and diagnosed the patient with EVALI and started him on methylprednisolone and a 5-day course of azithromycin for its anti-inflammatory effects. The patient was subsequently able to be weaned off oxygen and was discharged home on an oral prednisone taper and azithromycin after 6 days in the hospital. CXR 2 weeks after discharge was normal with complete resolution. Discussion: EVALI is mainly a diagnosis of exclusion and can mimic other infectious and rheumatologic conditions, therefore clinicians must maintain a high index of suspicion in order to make the diagnosis. Clinical manifestations of EVALI can include respiratory, gastrointestinal, and constitutional symptoms. The most frequently reported symptoms include shortness of breath, fever, cough, vomiting, diarrhea, dizziness, headache, tachycardia, and chest pain. Laboratory studies often show an elevated CRP and procalcitonin, leukocytosis, and a transaminitis. Radiographic features can include diffuse, bilateral, ground-glass infiltrates with basilar predominance and sub-pleural sparing. Conclusion: This case demonstrates the importance of obtaining a social history in a confidential environment in any adolescent case. When this was done on hospital day two, we learned of an extensive vaping history which helped us diagnose the patient with EVALI. In addition to drug use, clinicians should specifically ask about the use of e-cigarettes and vaping products since not all adolescents will divulge these details unless directly asked.

Environmental Factors.

The acute respiratory distress syndrome (ARDS) remains a major cause of morbidity and mortality in the intensive care unit. Improving outcomes depends on not only evidence-based care once ARDS has already developed but also preventing ARDS incidence. Several environmental exposures have now been shown to increase the risk of ARDS and related adverse outcomes. How environmental factors impact the risk of developing ARDS is a growing and important field of research that should inform the care of individual patients as well as public health policy.

The Association Between Vape Shop Density and E-cigarette, or Vaping, Product-Use Associated Lung Injury in Adolescents

Rationale: In 2019, the clinical manifestations of an outbreak of e-cigarette, or vaping, product useassociated lung injury (EVALI) in the United States was described and linked to vitamin E acetate, an additive used to dilute tetrahydrocanninol (THC). It is unknown whether access to vape shops influence adolescent e-cigarette literacy and increase the risk for EVALI. This study aims to elucidate associations between adolescent EVALI cases and neighborhood vape shop density. Methods: ZIP codes of EVALI cases in adolescents hospitalized at Children's Health Medical Center Dallas from December 2018 - June 2021 were retrospectively identified using the Centers for Disease Control and Prevention case definition. ZIP codes without EVALI cases were identified through the American Community Survey 2019 data and matched to the EVALI ZIP codes 2:1 using population size and age distribution. Vape shop locations were obtained by cross-referencing search results from Google Maps and Yelp. Vape shop density was mapped per ZIP code using ESRI ArcMap geospatial processing software. Hotspots were identified using graduated symbols. Data distribution of vape shop density was assessed with the Shapiro Wilk test for normality. Differences in vape shop density by ZIP code group (EVALI/no EVALI) was assessed with the Wilcoxon Rank Sum test. Results: The mean age of adolescents with EVALI (n=41) was 16.3 years (SD=1.1) (66% male;61% Hispanic, 39% non-Hispanic white). There were 34 corresponding ZIP codes, with five containing two EVALI cases and one containing three cases. 64% of our cohort were identified after the World Health Organization's declaration that COVID-19 was a pandemic, 66% obtained their vaping products from informal sources, 95% smoked primarily THC containing products, and 15% smoked “Dank” vapes. No significant difference in vape shop density was found between the 130 ZIP codes without EVALI cases (0.30 shops/mi2, SD=0.48) and the 34 ZIP codes with at least one EVALI case (0.24 shops/mi2, SD=0.24, p=0.98). Conclusions: Findings here show no association between ZIP code-level vape shop density and EVALI cases, suggesting that interventions should not be focused on regulating vape shops alone. This lack of association may be due to decreased vape shop accessibility during the COVID-19 pandemic and/or the origin of ecigarettes mainly from informal sources. Further research should investigate the association between other neighborhood characteristics and EVALI with the goal of implementing targeted prevention programs in at-risk neighborhoods to mitigate the impact of this new epidemic.

An Elusive Case of E-Cigarette, or Vaping, Product Use Associated Lung Injury (EVALI) Lacking Respiratory Symptoms

Introduction: Electronic vaping-associated lung injury (EVALI), attributed to inhalation through E-cigarettes and other devices was first characterized in the US in July 2019. By February 2020, 2807 cases were reported. Patients often present with respiratory, gastrointestinal, and constitutional symptoms. The presence of EVALI without respiratory complaints is under-recognized, only reported three times in the literature thus far. Case: A 22-year-old female student presented with five days of fever, watery, nonmucoid, non-bloody diarrhea, nausea, 3-4 episodes of vomiting, and generalized weakness, without cough, dyspnea, chest or abdominal pain. Social history revealed vaping e-cigarettes containing nicotine and tetrahydrocannabinol for the past 3-4 years with increased use recently due to upcoming exams. She denied smoking traditional cigarettes, marijuana, or illicit drugs. A temperature of 101oF and 98% SaO2 were recorded. Physical examination was notable for bilateral diffuse crackles with a normal abdominal examination. Initial labs demonstrated a WBC of 14,600 without a shift and the remaining labs were within normal limits. Despite the absence of respiratory symptoms, her chest radiograph revealed bilateral multifocal airspace disease. Further investigation with Chest CT showed extensive multifocal bilateral infiltrates and predominantly peripheral ground-glass opacities. COVID-19 PCR was negative three times. Influenza A and B, RSV, mycoplasma, and legionella testing were negative. She was unable to provide sputum for culture. Stool cultures were negative and an abdominal and pelvic CT was normal. She denied any history of dietary intolerances, prior diarrhea, or chronic colitis. Empiric treatment for atypical community-acquired pneumonia with intravenous ceftriaxone and azithromycin was initiated, with little improvement over the subsequent 4 days. Lack of clinical effect with antibiotics prompted a suspicion for EVALI and intravenous methylprednisolone 1mg/kg every 8 hours was initiated. There was a significant improvement of her gastrointestinal and constitutional symptoms within 24 hours. After three days of IV steroids, she was discharged on an enteral taper. A repeat Chest CT scan 2 weeks later demonstrated complete resolution of the previously identified ground-glass opacities. Discussion: The use of E-cigarettes has grown by 900% between 2011 and 2019 among young adults but used by older individuals as well. This has contributed to the burgeoning EVALI epidemic. Although COVID has taken the centre stage while identifying diffuse interstitial lung abnormalities, there must be a high index of suspicion regarding the incidence of EVALI, especially in young patients, considering the varied presentations and the potential absence of respiratory symptoms.

Vaping Induce Pneumonitis: Missed in Pandemic

Introduction: Coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a newly emergent coronavirus, that was first recognized in Wuhan, Hubei province, China, in December 2019. SARS-CoV-2 is a positive-sense singlestranded RNA virus that is contagious in humans. E-cigarette or vaping product use-associated lung injury (EVALI) is a type of acute lung injury of unclear pathogenesis. The two pathologies present with overlapping clinical symptoms, and imaging, making them difficult to distinguish, especially in global COVID-19 pandemic. Case report: 27-year-old female with past medical history of IBS, Diverticulitis, and anxiety presented with cough, shortness of breath, fever and fatigue. She also reported headaches and abdominal pain, she denies sick contact and recent travel but admit that she uses E cigarette more than usual due to anxiety attack. Patients initially discharge from ED but subsequently admit to hospital for worsening of symptoms possible COVID pneumonia vs community acquired pneumonia. She was persistently hypoxic and transfer to ICU for acute hypoxic respiratory failure. Labs was significant for elevated WBC while serum chemistries were unremarkable, Chest x-ray was not significant for any acute pathology. CT scan show revealed parenchymal changes consistent with bilateral upper and lower lobe ground-glass opacities. No septal change was noted, helping us rule out causes such as organizing pneumonia, lipoid pneumonia, and diffuse alveolar damage. Extensive testing for viral and bacterial infections was all negative. she has Covid19 PCR negative twice. Bronchoalveolar lavage testing was not done as patient refuse for invasive intervention. Patient started on steroids. Discussion: EVALI is thought to be a type of acute lung injury with an unknown pathogenesis. E-cigarette use, especially those containing THC and/or vitamin E acetate, is a key risk factor for developing the disease process. COVID 19 pneumonitis and EVALI have same clinical presentation, laboratory studies and images, and make challenge for physician to differentiate both pathologies. Both disease present with similar initial symptoms, including cough, shortness of breath, fevers, vomiting, diarrhea and headache. Similarly, laboratory studies may be unremarkable or elevated in both presentations and do not help distinguish between them. Furthermore, Chest X-ray and CT have very similar findings in both presentations, including diffuse hazy or consolidative opacities and ground-glass opacities, respectively. As well, both COVID-19 and EVALI are associated with worse outcomes in older adults or those with underlying chronic conditions, including cardiac and pulmonary disease.

Pneumonitis Due to “Dabbing” Successfully Managed via Extracorporeal Membrane Oxygenation

INTRODUCTION: E-cigarette or vaping associated lung injury (EVALI) is an uncommon complication of e-cigarettes or vaping. 96% of these cases require hospitalization. The condition is especially associated with tetrahydrocannabinol (THC) products, frequent use, and is found primarily in young adults. “Dabbing” refers to the process of heating THC containing oils or waxes with butane solvents to vaporize cannabinoids for inhalation. CASE REPORT: An obese 20-year-old college male with a history of prematurity and anxiety presented with cough, dyspnea, nausea, vomiting and diarrhea that began 3 days prior. He reported smoking marijuana, but denied vaping. Multiple PCR tests for SARS-CoV-2 were negative. Initial chest radiograph demonstrated multifocal pneumonia. He was hypoxic on presentation requiring two liters of oxygen via nasal cannula. Broad spectrum antibiotics for pneumonia and steroids were initiated. Oxygen requirements rapidly increased and humidified high flow oxygen was instituted and escalated to 60 liters per minute and 90 % FiO2. He remained hypoxic, prompting intubation 48 hours from presentation. His ventilatory settings were steadily escalated to a positive end expiratory pressure of 15 cm H2O with 100% FiO2. Despite this, the patient had oxygenation saturations as low as 57% requiring transition to venovenous extracorporeal membrane oxygenation (VV-ECMO). Computed tomography angiography ruled out pulmonary embolism but redemonstrated extensive alveolar and interstitial infiltrates bilaterally. Bronchoscopy with alveolar lavage was performed with negative cultures and cytology. Blood cultures were also negative and antibiotic therapy was stopped. Extensive laboratory investigation for autoimmune vasculitis was performed and found to be negative. Discussion with family revealed that the patient regularly inhaled concentrated THC wax with butane as a solvent. Treatment continued with high dose intravenous steroids and supportive care. The patient received a total of 5 days of ventilator support after which he was extubated, and an additional 5 days of VV-ECMO. At discharge, the patient required 2 liters of continuous oxygen at rest and 4 liters with activity. He was otherwise asymptomatic and at his baseline level of function. He was discharged on daily steroids with taper and close outpatient follow up. DISCUSSION: While the majority of hospitalized patients with EVALI require intubation, the necessity of VV-ECMO utilization represents a rare severe presentation. Dabbing remains a rare cause of acute respiratory distress syndrome and EVALI, however, dabbing is emerging as a trend among young adults and represents an under-investigated cause of severe inhalational lung injury.

It is not always COVID-19: a case of respiratory failure from lung damage associated with electronic cigarettes (EVALI)

Objective: In the period of the SARS-COV-2 pandemic, the differential diagnosis between several causes of respiratory failure can represent a challenge for clinicians. We present the case of an adolescent with e-cigarette associated lung injury mimicking COVID-19 presentation. Case report: A previously healthy 14-year-old male was transferred to our Pediatric Intensive Care Unit for respiratory distress and history of contact with a SARS-COV-2 positive schoolmate. At admission he was febrile, tachycardic, tachypneic, and hypoxic. The laboratory findings showed increased inflammatory markers. Chest computed tomography (CT) showed ground glass opacities (GGO) predominantly in the lower lobes with sparing of the subpleural region, parenchymal consolidation with areas of lobular sparing (“atoll sign”), centrilobular nodules of GGO and nodular consolidation were visible. He was suitably isolated and treated with non-invasive ventilation. The infectious workup, including respiratory viruses, SARS-CoV-2, as well as blood and bronchial cultures, was negative. After further questions, the boy admitted that he had been vaping nicotine for more than 90 days. According to the definitions of the Centers for Disease Control and Prevention, lung damage associated with the use of vaping products (EVALI) was diagnosed [1] and methylprednisolone was started at 2mg/kg/day. Following gradual improvement, he was transferred to the pediatric ward on the fourth day. Conclusion: The incidence of vaping has more than doubled from 2017 to 2019. COVID-19 and EVALI share clinical symptoms and radiological findings, however the negativity of microbiological investigations and the history of vaping may help in the differential diagnosis. Additionally, as in our case, EVALI CT may present subpleural sparing, slight lower lobe predominance, centrilobular nodules and the atoll sign [2]. Finally, correct identification and early therapy of EVALI can improve the outcome and minimize the length of hospital stay. In patients presenting with unexplained respiratory failure, excluding COVID-19, the possibility of EVALI should be carefully evaluated as the treatment of EVALI differs from COVID-19.

42nd International Congress of the European Association of Poisons Centres and Clinical Toxicologists

The proceedings contain 209 papers. The topics discussed include: an illicit drug early warning system utilizing comprehensive toxicological analysis of emergency department presentations in Victoria, Australia;4-fluoroamphetamine (4-FA) intoxication results in exaggerated blood pressure effects compared to 3,4-methylenedioxymethamphetamine (MDMA) and amphetamine: a retrospective analysis;single nucleotide polymorphisms of mu opioid receptor gene OPRM1 in emergency department patients with acute opioid overdose;ketamine in acute recreational poisonings in the Balearic Islands;the neuro-respiratory effects of pregabalin and the potential deleterious effects of its combination with diazepam or morphine ? a rat investigation;cobaltism from metal-on-metal (MoM) hip implants: how to manage and treat with acetylcysteine;analytically-confirmed polydrug use is more common in drug misuse patients attending emergency departments in Scotland compared with those in England and Wales;and it is not always COVID-19: a case of respiratory failure from lung damage associated with electronic cigarettes (EVALI).

HYPERSENSITIVITY PNEUMONITIS OR EVALI? A CASE OF ACUTE RESPIRATORY FAILURE IN AN ADOLESCENT

Introduction: Hypersensitivity pneumonitis is an interstitial lung disease caused by lymphocytic response to inhalant exposures such as molds or avian excreta. Given its complexity and variation in presentation, the diagnosis of hypersensitivity pneumonitis requires obtaining a detailed exposure history and thorough workup. Case Description: A 17-year-old previously healthy female without asthma history developed cough, fever, and shortness of breath. A week later, she was intubated for acute respiratory failure. Her initial imaging revealed pneumomediastinum and pneumopericardium with ground glass opacities. The etiology of her respiratory failure remained unclear. Infectious workup, including multiple COVID tests, was negative. Given that she cares for horses, a hypersensitivity pneumonitis panel was done and revealed elevated aspergillus fumigatus IgG level >200 mcg/mL and total IgE of 571 kU/L. BAL showed elevated neutrophil count and lung biopsy was not obtained. She was extubated after a week and subsequently revealed that she vapes marijuana. This introduced e-cigarette and vaping associated lung injury (EVALI) as another etiology for her presentation. She ultimately completed an extended course of steroids and was discharged on supplemental oxygen. Discussion: Our patient presented with acute respiratory failure and negative infectious workup. Initial social history revealed frequent exposure to horse barns, leading to a diagnosis of hypersensitivity pneumonitis. However, it was subsequently revealed that she vaped, which introduced EVALI as another possibility. While her final diagnosis remains nebulous, this case highlights the importance of maintaining a broad differential during assessment of acute respiratory failure and the critical role that astute history taking plays in the diagnostic process. [Formula presented]

A case of e-cigarette/vapingassociated lung injury in the era of COVID-19

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.

Acute Respiratory Distress Syndrome During the COVID-19 Era

During the current pandemic, the 2019 novel coronavirus (SARS-CoV-2) has quickly moved to the top of the list of potential causes of acute respiratory distress syndrome (ARDS) in patients presenting to the hospital. Potential COVID-19 infections should continue to be quickly identified and treated when indicated, but it is important that we not forget about the other potential causes of ARDS. In this case series, we will discuss 3 cases of ARDS that were passed off as likely SARS-CoV-2 infections but were all discovered to be negative for COVID-19. This highlights the importance of maintaining a thorough history and physical examination during the pandemic to identify the other causes of ARDS and avoid the negative effects of frequency bias.

Vaping, SARS-CoV-2, and Multisystem Inflammatory Syndrome: A Perfect Storm.

The use of electronic cigarettes (e-cigarettes) and vaping among adolescents has risen exponentially in the last decade. E-cigarette flavors has driven adolescents to use these convenient, USB-like devices, designed to create a desired social image, while being seemingly unaware of the serious health consequences of their behavior. Vaping impacts protective pulmonary barriers by attenuating the mucociliary clearance and by increasing peribronchial inflammation and fibrosis. The recent SARS-CoV-2 (COVID-19) pandemic has been characterized by a plethora of unusual disease presentations. Among them, a unique presentation seen exclusively in children and adolescents was multisystem inflammatory syndrome (MIS-C). Seventy percent of adolescents who had MIS-C also had acute respiratory distress syndrome (ARDS), and we speculate that there may exist common denominator that links MIS-C and adolescents: the use of e-cigarettes. The virus targets the angiotensin converting receptor (ACE receptor), and studies have shown nicotine-based e-cigarettes or vaping cause oxidative stress and resulting in the upregulation of ACE2, which might worsen ARDS in MIS-C. Our mini-review highlights that adolescents using e-cigarette have alterations in their pulmonary defenses against SARS-CoV-2: an upregulation of the ACE2 receptors, the primary target of SARS-CoV-2. Their compromised immune system makes them more uniquely vulnerable to Covid-19 related MIS-C, increasing their risk for ARDS and related morbidities. Currently, studies have shown an association between MIS-C and vaping, we speculate that adolescents who vape/smoke might be especially vulnerable to serious respiratory symptoms if they develop a hyper-inflammatory state MIS-C.