In a world of horses, don't miss zebras: A case of e-cigarette or vaping use-associated lung injury (EVALI) in the COVID-19 era

INTRODUCTION: E-Cigarette use or vaping has rapidly become the most common alternative to traditional tobacco smoking among youth. The use of e-cigarettes is still highly controversial from medical, scientific and psychological standpoints because of the insufficient formal research available on the effects of vaping on the public health. Moreover, as of September 2019;CDC and FDA started a wide investigation after a multistate outbreak of lung injury associated with e-cigarette products use (EVALI). Here, we present a case report of EVALI in the COVID-19 era that was initially isolated for a high suspicion of COVID-19 pneumonia due to its similarities. CASE PRESENTATION: 20-year-old female presented to the hospital with worsening dysnea, productive cough with gray/yellow sputum, nausea, vomiting, and fever for 1 week. She was in severe respiratory distress and was subsequently sedated and intubated. Lung examination was consistent with diffuse rhonchi throughout the lungs. Chest radiograph showed bilateral extensive areas of parenchymal infiltrates concerning for atypical infectious process. Computed Tomography (CT) scan of chest showed bilateral lower lobe consolidation with air bronchograms and reticulations. Laboratory workup was remarkable for leukocytosis with lymphopenia, and elevated inflammatory markers and transaminases. Due to high suspicion of COVID-19, nasopharyngeal specimen was sent for PCR analysis, and isolation precautions were initiated. Patient was started on empiric antibiotics and steroids. Influenza antigen, streptococcus pneumonia, legionella and mycoplasma were all negative. Upon further questioning, her mother reported that the patient has recently started vaping and uses orange juice in her vape. COVID-19, MRSA screen, and sputum culture were all negative. Pro-calcitonin was negative. Patient was extubated and showed significant improvement. She was discharged home with supplemental oxygen. DISCUSSION: According to CDC statistics in 2018, more than 3.6 million U.S middle and high school students used e-cigarettes in 30 days. Among current users aged 18-24 years, 40% had never been regular cigarette smokers. E-cigarettes use has been linked to hazardous adverse effects, most importantly EVALI, through triggering cytokine expression, airway hyper-reactivity, altered mucin secretion, oxidative stress and lung tissue destruction. A wide range of imagining discrepancies has been described in EVALI, including acute lung injury, organizing pneumonia, hypersensitivity pneumonitis and diffuse alveolar hemorrhage. COVID- 19 pandemic has made diagnosing EVALI even more challenging due to the overlap of their clinical, laboratory and radiological features, necessitating a high index of suspicion and a thorough history and physical examination. More data is needed to increase our knowledge of this disorder.