Vape-Associated Pulmonary Injury (VAPI) Presenting With a "Miliary" Pattern on Imaging

Electronic (E)-cigarette use or vaping is associated with pulmonary injury. Users can present with wide-ranging symptoms, varying degrees of pulmonary injury, and respiratory distress. Lung injury secondary to vaping is associated with a variety of patterns on pulmonary imaging. Typical radiographic findings are consistent with bilateral, basilar ground-glass opacities and or consolidation with septal thickening. We present a case of vape-associated pulmonary injury (VAPI) in a previously healthy adult who was found to have atypical radiographic findings. A 34-year-old male presented with a chief complaint of a two-week history of malaise, nausea, cough, and worsening shortness of breath. A chest CT scan without contrast revealed diffuse nodules in a miliary pattern. The patient reported a six-month history of tetrahydrocannabinol (THC) vape use. Bronchoscopy with cytologic analysis confirmed findings consistent with the VAPI. To our knowledge, this is the first report of a "miliary" pattern of infiltrates and nodules in a patient with VAPI. This pattern on CT imaging led to increased suspicion for other possible etiologies, including tuberculosis. Thus, moving forward, we believe that VAPI needs to be considered in the differential diagnosis if a patient presents with radiographic findings consistent with a miliary or diffuse micronodular pattern.