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

ABSTRACT

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.