ABSTRACT
E-cigarette-/vape-associated lung injury (EVALI) refers to damage to lung tissue occurring as a result of e-cigarette utilization or via vaping of inhaled nicotine products. Vaping refers to the practice of inhaling an aerosol derived from heating a liquid or gas containing substances such as nicotine, cannabinoids, flavoring, or additives. Battery-operated e-cigarettes or vape pens are the vessels commonly used in this practice. EVALI, first described in the literature in 2019, has a non-specific course, presenting initially with cough and dyspnea. It can progress, however, to interstitial lung disease or result in damage to the lung parenchyma with concomitant inflammation and fibrosis. Imaging findings reflect the development of this inflammation and fibrosis, often visualized as ground-glass opacities on computed tomography (CT) scans. Formal biopsies are not required to make the diagnosis of EVALI, and thus, a gap exists in the scientific literature with regard to the pathology of lungs exposed to non-tetrahydrocannabinol (THC) e-cigarettes. The following case details the clinical course of a 62-year-old male who presented to the outpatient pulmonology office with symptomology and exposure history consistent with EVALI, unique in presentation due to the timeline of his disease development. The patient initially presented to the clinic for the evaluation of a non-productive cough and exertional dyspnea beginning one year ago, with an associated new home oxygen requirement of 2 liters via nasal cannula. The patient's past medical history was relevant for diffuse large B-cell lymphoma treated with the chemotherapeutic regimen that consists of etoposide phosphate, prednisone, vincristine sulfate (Oncovin), cyclophosphamide, doxorubicin hydrochloride (hydroxydaunorubicin), and rituximab, commonly known as EPOCH-R, as well as a social history relevant for a 35-pack-year smoking history. On further questioning, the patient revealed that following cessation of cigarette smoking, he began using non-THC e-cigarettes daily and had been doing so for 10 years prior to symptom onset. Imaging and biopsy findings consisted of a CT of the chest demonstrating concern for interstitial lung disease and an open lung biopsy demonstrating diffuse alveolar damage with eosinophilia. Given the patient's history, clinical symptoms, and imaging findings, a diagnosis of EVALI was established. This case was documented not only to increase awareness of the rising incidence of EVALI as the use of e-cigarettes and vapes becomes increasingly popular but also to further understand the inhalational injury sustained from non-THC e-cigarettes and other inhalational practices.
ABSTRACT
A 14-year-old male presented to the sports medicine clinic for evaluation of right lateral knee pain for three weeks after he took a forceful blow to his right lateral knee during a football game. He reported swelling and bruising and increasing pain since then. Physical exam was significant for an area of fluctuance that was approximately 20 cm in length and 10 cm in width overlying the lateral right knee with associated ecchymosis and decreased sensation. The remainder of the exam was benign. Point-of-care ultrasound showed a large hypoechoic space overlying the lateral knee consistent with a Morel-Lavallée lesion (MLL). Twenty-six milliliters of serosanguinous fluid were aspirated from between the fascial planes, deep to subcutaneous fat but superficial to quadriceps muscles, under ultrasound guidance. The lesion was sclerosed with 1 cc 1% lidocaine without epinephrine and 4 cc dexamethasone 4 mg/mL, and the patient was given compression wrappings to wear for the next four weeks. MLLs are collections of fluid that occur between different planes of subcutaneous tissue following blunt force or shearing trauma. The general mechanism of injury is a closed degloving injury that occurs following damage to the potential space between layers of fascia, dermis, and subcutaneous fat. MLLs are relatively rare lesions and, when identified, are most frequently found in the proximal thigh and associated with serious underlying bony fractures. MLLs are uncommon and difficult to diagnose due to their nonspecific findings of fluctuance, pain, and bruising. This case is unique in its presentation of an isolated MLL in the lateral knee. Early diagnosis and intervention of these lesions prevent further sequelae.
