A previously healthy 18-year-old female presented to the Emergency Room after one day of fever, nonproductive cough, difficulty breathing, and pleuritic chest pain. Two months prior to presentation she started vaping using a "Baby Smok Beast Mod" device with 6% nicotine fluid 5 times per day for 30 minutes. She denied traditional cigarette smoking, drug use, exposure to pulmonary irritants, recent respiratory illness or history of deployment to the Middle East. Initial vitals were remarkable for oxygen saturation of 88% on room air, temperature of 102.4  F, heart rate of 122 beats/min, respiratory rate of 22 breaths/min, and blood pressure of 104/68 mm Hg. On physical exam, she was found to be in mild distress with tachycardia, tachypnea and facial flushing. There was neither accessory muscle use nor chest wall tenderness, and her lungs were clear to auscultation bilaterally. There was no lower extremity edema or calf tenderness. Laboratory tests revealed significant leukocytosis of 19.6 x 109/L with 91.2% granulocytes and 0.5% eosinophils. Initial chest x-ray demonstrated right lower lung airspace consolidation consistent with a pneumonia. Intravenous azithromycin was initiated and she was admitted to the hospital for further monitoring. Overnight, she developed moderate distress with worsening tachycardia, dyspnea, and hypoxemia. Increasing levels of oxygen by nasal cannula were required to maintain her oxygen saturation above 92%, meanwhile her respiratory rate increased to 30 breaths/min. Repeat examination revealed bibasilar inspiratory crackles. D-dimer was elevated to 0.79 mcg/ml. Repeat chest radiograph demonstrated increasing airspace opacities. A computed tomography pulmonary angiogram (CTPA) was completed due to concern for pulmonary embolism (PE). The CTPA excluded PE, but found diffuse ground-glass patchy airspace disease and coalescing nodules (Fig. 1).
Due to worsening respiratory failure overnight, the patient was transferred to the Intensive Care Unit (ICU) for closer monitoring and respiratory support. Bronchoscopy with bronchial alveolar lavage (BAL) was performed, revealing 26% eosinophils in the lavage fluid. Sputum and BAL cultures were negative for viral, fungal, and bacterial pathogens. No other infectious etiologies to include TB, legionella, strongyloides, coccidioides, or histoplasma were found. Given her acute onset of symptoms, negative alternative workup, and significant BAL eosinophilia the diagnosis of AEP was made. She was started on methylprednisolone 125mg intravenous every 6 hours. After two days she showed significant improvement and was switched to prednisone 60mg oral once daily. She fully recovered 6 days after starting steroids, and was discharged home on oral prednisone with subsequent tapering. On discharge, her vital signs and physical exam were within normal limits. A repeat chest x-ray performed on the day of discharge showed significant improvement of the airspace opacities bilaterally (Fig. 2).