Introduction
“Vaping” is the process in which liquid substances such as nicotine or Tetrahydrocannabinol (THC) are heated in a device and the aerosolized particles are inhaled. Several devices are available on the market with the most common being e-cigarettes and vaping pens1. The substances used in vaping pods can contain additives to aid in aerosolization and flavoring to increase marketability to adolescents2. One of the most common additives is Vitamin E acetate which in combination with THC has been shown to cause increased inflammation and alveolar damage leading to E-cigarette or Vaping product use Associated Lung Injury (EVALI)3. EVALI was first described in 2019 and as of January 14, 2020 according to the CDC data, there have been 2668 hospitalized patients and 68 deaths caused by EVALI. Of these hospitalized patients, 66% were male. 82% of patients reported using THC containing products and 33% reported sole use of THC products.4
Although no specific tests or markers are available for the diagnosis of EVALI, there are certain characteristic presenting features. Patients present with an acute respiratory illness (cough, shortness of breath and/or chest pain), constitutional symptoms (fever, chills) and/or gastrointestinal symptoms (abdominal pain, nausea, vomiting, and diarrhea) in addition to a positive history of e-cigarette or vaping use.3,5 These symptoms are non-specific and can be due by other respiratory viruses causing pneumonia thus making EVALI a diagnosis of exclusion.
Coronavirus disease 2019 (COVID-19), caused by the SARS-CoV-2 virus, was first discovered at the end of 2019 in Wuhan, China. The first reported cases in the United States were in January 2020 and its rapid spread was labeled a pandemic by the World Health Organization in February6. The symptoms of COVID-19 in children are very similar to EVALI and include fever, cough,shortness of breath and gastrointestinal symptoms like abdominal pain,vomiting,diarrhea and nausea.7,8,
At the Bristol Meyers Squibb Children’s Hospital located in Central New Jersey, coincident with the surge of the COVID-19 pandemic in New Jersey, we noted a 6-fold increase in the number of EVALI cases from March 2020 to June 2020,compared to the 1 year period prior to the start of the COVID surge. We present a series of twelve patients initially suspected to have COVID-19 pneumonia but were subsequently diagnosed with EVALI. We describe the diagnostic dilemma that we were initially presented with.
Table 1 describes the demographics,clinical findings,laboratory findings,and respiratory support for each patient.
Two cases (Cases #2and #4) were chosen from the series of 12 to highlight the overlapping features between EVALI and COVID. This study was approved by the Rutgers-Robert Wood Johnson Medical School Institutional Research Board.