Discussion
This case series describes twelve pediatric patients with EVALI who
presented during the COVID-19 pandemic surge in New Jersey. All patients
presented with clinical, laboratory and/or radiological findings that
raised suspicion of COVID-19 but subsequently tested negative for
COVID-19 by RT-PCR nasopharyngeal swab, in some cases multiple
times(Cases# 9,10). According to the CDC, confirmed cases of EVALI have
history of e-cigarette use 90 days prior to presentation, pulmonary
infiltrates on CXR or CT scan, absence of pulmonary infection at initial
presentation either by culture or respiratory viral panel, no alternate
plausible diagnosis9.Our patients reported vaping
anywhere from 3 months to 5 years prior to admission. All but one of our
patients(Case #8) fit the CDC definition of EVALI.
It is possible that some of the patients had COVID-19 but their tests
were false negatives, either due to the sensitivities in the RT-PCR test
or errors in collecting the sample.17,18 However, many
of the patients were tested multiple times and remained negative making
the diagnosis of COVID pneumonia much less likely. Additionally, cases
10,11 and 12 had SARS-COV-2 IgG antibody testing done, which was also
negative, however the antibody was done within a week of presentation.
Antibody testing was not available when the cases 1-9 presented. However
SARS-COV-2 IgG antibody was negative in case#8 six weeks after onset of
symptoms.
Studies describing the clinical features of EVALI and COVID-19 in
pediatric patients are relatively recent. Both EVALI and COVID-19
pediatric patients can present with fever, cough, shortness of breath
and chest pain10-12. Both can also present with
nonspecific gastrointestinal symptoms such as abdominal pain, nausea
vomiting and diarrhea 5. We are not aware of any
studies that have compared the clinical presentation of these two
entities in children.
Radiological findings in EVALI pediatric patients can show diffuse
bilateral symmetric ground-glass lung opacities, consolidation and a
lower lobe predominance on CT.13. While the data on
pediatric COVID-19 CT imaging is scarce, a large study in the adult
population by Bernheim et.al. described that the typical COVID-19 CT
scan would show “bilateral and peripheral ground-glass and
consolidative pulmonary opacities” however many patients had CT scans
that lacked all or some of those features14,15.
Radiological features are not specific to these conditions and there are
no specific features to distinguish EVALI from COVID-19 on chest
imaging. Figure 2 shows CT images of a 19 year old patient who was
admitted with EVALI and a 21 year old male who was admitted at the same
time with COVID pneumonia.
Laboratory findings in both COVID-19 and EVALI can show elevated liver
function tests, inflammatory markers such as ferritin, d-dimer,
C-reactive protein, and procalcitonin and
coagulopathy16-18.Coagulation abnormalities and
inflammatory dysregulation have been described in both EVALI and
COVID-19. Khanijo and colleagues described elevated inflammatory markers
such as CPR, ESR and procalcitonin in their series of 24 patients with
EVALI. Hematological,biochemical , inflammatory and immune marker
abnormalities have been described in COVID-19 and they are used for risk
stratification in the disease19 . All patients in our
series demonstrated abnormalities in coagulation profile.
Lymphopenia has been described as a feature of COVID-19.20This has not been described in EVALI and could be a
helpful distinguishing feature between the two conditions. None of our
patients had lymphopenia. However, in pediatric COVID-19 cases only a
small proportion of patients exhibit Lymphopenia.21
In our series, patients who presented early in the COVID surge were
started on Hydroxychloroquine, which was the recommendation at that
time7. Many of these patients were tested multiple
times (up to 3 times) and were treated with therapies aimed at treating
COVID-19 such as Hydroxychloroquine. Early in the surge steroids were
contraindicated in patients with COVID-19 and were therefore withheld
till results became available. Only after a thorough history uncovered
vaping use and other causes of pneumonia ruled out was treatment with
steroids begun, generally on hospital day 2 or 3, depending on when the
results of COVID testing were available. The currently recommended
treatment of EVALI includes use of dexamethasone22with several studies showing short term benefit including decreasing
mortality rates. Steroids were contraindicated for the treatment of
COVID early in the pandemic however recent emerging data are supporting
the use of steroids.
There are several factors that have been implicated in the higher
susceptibility of smokers and vapers to COVID-19.Vaping causes increased
mucosal permeability and impaired muco-ciliary clearance, which is the
first line of defense23. Additionally, smokers
are shown to have a higher surface expression of ACE2 receptors, which
is the binding site for SARS-CoV224.
It is possible that due to the shelter in place order in our area with
schools and workplaces closed during the pandemic surge, adolescents are
finding more opportunities to vape beyond the reach of principals and
teachers9. This is likely exacerbated by the fact that
those who vape are more likely to have underlying anxiety and depression
and isolation has been shown to cause increased stress and
depression25,26Four of the 12 patients in this series
had an underlying mental health diagnosis.
Given the commonalities in presentations, but differences in treatments
between the two relatively new diseases, COVID-19 and EVALI, it remains
crucial to elicit a detailed social and substance use history in
patients presenting with ‘typical’ COVID pneumonia like illness. Given
the ongoing pandemic, Pediatricians and other health care providers need
to be aware of other conditions that can masquerade as SARS-CoV-2.