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.