Abstract Introduction Adolescents presenting with acute respiratory distress are often treated empirically for pneumonia or asthma exacerbation but sometimes the true culprit is less obvious. E-cigarette or vaping product use-associated lung injury (EVALI) is an emerging threat capable of causing rapid hypoxemic respiratory failure and mimicking common pulmonary illnesses. We describe a 15-year-old female whose presentation initially suggested pneumonia, but refractory course and characteristic imaging ultimately revealed EVALI, highlighting the diagnostic challenge and the importance of identifying vaping-related lung injury in adolescents. Case Presentation A 15-year-old female, who had been vaping since age 11, presented with shortness of breath, cough, periumbilical abdominal pain, intermittent non-bloody vomiting, and poor oral intake for one week. Her mother noted “belly breathing” and worsening wheezing, prompting urgent evaluation. Her respiratory history included persistent cough and nocturnal wheezing for three years following COVID-19 pneumonia, though she had never received a formal asthma diagnosis. On initial evaluation, patient was febrile, tachypneic and tachycardic. CBC revealed leukocytosis, with otherwise normal indices, and CMP showed mild hypokalemia. Initial chest X-ray suggested pneumonia, and she was started on albuterol and Ampicillin. Despite therapy, her condition worsened, with escalating hypoxemia requiring ICU transfer for Vapotherm and CPAP support. A chest CT demonstrated diffuse bronchial wall thickening, multifocal subsegmental ground-glass opacities, and a focal right middle lobe opacity with scarring, without evidence of fibrosis (Figure 1). Combined with her recent vaping history, these findings confirmed EVALI. Following diagnosis, she was treated with high-dose azithromycin (10 mg/kg daily × 5 days, then 5 mg/kg every other day for four weeks) and a 10-day course of prednisolone (30 mg twice daily). Her respiratory status improved rapidly, oxygen requirements decreased, and she was successfully weaned off respiratory support. Discussion EVALI is a clinical chameleon, often mimicking pneumonia or asthma exacerbations. Since its recognition in 2019, EVALI has challenged clinicians due to overlapping symptoms, nonspecific imaging, and variable disease severity. The underlying pathophysiology involves alveolar inflammation and surfactant disruption caused by inhaled toxins such as vitamin E acetate. Management requires prompt cessation of vaping, supportive respiratory care, and systemic corticosteroids, which often lead to rapid recovery. Adjunctive macrolide therapy, such as azithromycin, may provide additional anti-inflammatory benefit. This case underscores the importance of obtaining a detailed vaping history and considering EVALI in adolescents with unexplained or refractory hypoxemia. Early recognition and intervention can prevent prolonged ICU stays, reduce complications, and lead to full recovery. This abstract is funded by: None
Aldajeh et al. (Fri,) studied this question.