A 17-year-old male presented to the emergency department (ED) with fever, cough, congestion, nausea, and vomiting. He was seen by his pediatrician 3 days prior and was given azithromycin and oseltamivir albeit a negative rapid influenza test as well as a negative Streptococcus pyogenes test. His vomiting and nausea had worsened since starting oseltamivir with almost no per oral tolerance, and hence he was brought to the ED for fluid resuscitation and IV nausea medication. The patient also mentioned experiencing intermittent diarrhea for months, especially associated with food intake. He denied any chest pain, shortness of breath, palpitations, dizziness, lightheadedness, weakness, numbness, tingling, constipation, dysuria, hematuria, hematochezia, and melena. Physical examination revealed mild-to-moderate dehydration with dry oral mucosa. At the ED, patient's oseltamivir was discontinued, and his fluids were replenished. His leukocyte count was 12,000 cells/mm3, erythrocyte sedimentation rate (ESR) was 53 mm/hr, and chest X-ray showed mild infiltrates versus artifact. He was sent home on ondansetron and instructed to continue the azithromycin and follow-up with his pediatrician within 1 week and return to the ED for worsening symptoms.
The patient returned to the ED 2 days later with profuse vomiting, diarrhea, and abdominal pain worse in the right lower quadrant. Inflammatory markers at this time included a C-reactive protein (CRP): 260 and an ESR: 79. He was given fluids, ondansetron and morphine, to treat his nausea and pain, respectively. A computed tomography (CT) with intravenous contrast of his abdomen and pelvis showed no acute intra-abdominal findings but a possible pneumonitis in the lung bases bilaterally. Upon returning from the CT, his oxygen saturation was 80% on room air. He was placed on 3L nasal cannula with immediate improvement to 95% saturation. At this visit, the patient finally admitted to cough and intermittent shortness of breath. A chest X-ray (Figure 1) at this time showed multifocal pneumonia. He was started on ceftriaxone and azithromycin and admitted to the pediatric service.
Upon admission to the pediatric service, the patient endorsed fevers, sore throat, shortness of breath, right lower and substernal chest pain, nausea, vomiting, and diarrhea and denied any recent travel, exposure to sick contacts, anxiety, depression, rashes, hematuria, or hematochezia. A comprehensive cardiac, gastrointestinal, and infectious workup was completed including stat labs for complete blood count (CBC), basic metabolic panel (BMP), blood culture, Mycoplasma pneumoniae titers, urinalysis, stat echocardiogram (ECHO), electrocardiogram (EKG), troponins and B-type ventricular natriuretic peptide (BNP) with cardiac consult, D-dimer, and gastrointestinal stool panel. At this time, the patient continued to remain on 3L supplemental oxygen to maintain saturations above 90%. Laboratory results revealed a normal white blood cell count (WBC), negative blood cultures and mycoplasma titers, hypokalemia, dehydration, acute kidney injury (AKI), unremarkable EKG, ECHO, troponins and BNP, and an elevated D-dimer at 0.93 mcg/ml. Overnight, the patient was continued on appropriate IV fluids and oral potassium chloride (KCl) to correct his dehydration status, AKI, and hypokalemia. The patient continued to exhibit worsening respiratory distress clinically with oxygen support titrated up to 6L. A chest CT angiography (Figure 2) was performed which ruled out a pulmonary embolus but was notable for diffuse airspace opacities, primarily within the lower lobes, with a ground-glass appearance concerning for acute respiratory distress syndrome. At this time, the patient had been weaned down to 4L supplemental oxygen. Though the nausea and vomiting were controlled with IV ondansetron, diarrheal episodes persisted. GI panel at this time was negative.
Upon further investigation of his social history, the patient admitted to vaping nicotine products for the past 4 years and tetrahydrocannabinol (THC) products within the last several months. He was started on prednisone 30 mg twice a day and eventually weaned to 2L oxygen. The antibiotics were discontinued. Within 24 hours of initiating oral steroids, the patient was weaned to room air and was breathing well and comfortably, along with resolution of his diarrhea. Inflammatory markers also began trending down since admission.
The patient was diagnosed with e-cigarette or vaping product use-associated lung injury (EVALI). He was discharged on a steroid wean over 12 days and was agreeable to vaping cessation. The patient was followed outpatient with pulmonology 1 month after discharge with pulmonary function tests showing normal diffusion capacity and normal pre- and postbronchodilator spirometry, with no evidence of air trapping.