An alternative diagnosis for vape induced lung injury: a case report

Vaping can result in acute and severe respiratory distress, a condition known as e-cigarette or vaping-associated lung injury (EVALI). The inhalation temperature of e-cigarettes can reach up to 315-400 °C (600-750 °F). EVALI is characterized by a range of clinical and pathological findings, including pulmonary infiltrates, diffuse alveolar damage, but mainly ground-glass opacities. This case report presents a case of severe lung injury needing extracorporeal membrane oxygenation (ECMO) as a result of vaping, but not with the standard presentation or clinical findings or the standard diagnosis.

A 17-year-old Dutch woman with a history of asthma, presented to the emergency department with respiratory distress after vaping up to 600 inhalations daily for several days. The evening prior to admission, the patient experienced three episodes of acute breathlessness accompanied by wheezing and coughing, preceded by 4-5 days of headache and cold symptoms. Though there was initial improvement at the hospital, her condition rapidly deteriorated with silent chest, tachypnea at 70/min, increased respiratory effort with nasal flaring, and muscle retractions. Despite receiving mechanical ventilation and the treatment for a possible status asthmaticus her condition continued to deteriorate. Due to the severeness of the respiratory distress, she was transferred to the Erasmus Medical Center (EMC) for ECMO. Imaging studies at the EMC, including chest CT, revealed severe subcutaneous emphysema and pneumomediastinum without a pneumothorax, as well as severe central and peripheral mucus plugs. Bronchoscopy confirmed severe bronchial obstruction with epithelial shedding with easy bleeding epithelial. After 17 days of ECMO support, the patient showed signs of improvement and was successfully weaned off ECMO. However, she experienced muscle weakness, necessitating prolonged mechanical ventilation and tracheostomy placement. After a total of 26 days in the ICU, she was transferred to the general ward without supplemental oxygen.

This case suggests a severe vaping-associated lung injury with features of inhalation injury, rather than classical EVALI. Adequate and critical evaluation of patients with respiratory distress after vaping should be performed.