Abstract Introduction E-cigarette or vaping-associated lung injury (EVALI) is an acute or subacute inflammatory lung disease linked to e-cigarette use, typically presenting with diffuse alveolar damage and organizing pneumonia. Most cases are reversible with corticosteroid therapy and cessation of vaping. However, a subset of patients develop progressive or fibrotic interstitial changes despite treatment. Recognition of these atypical forms is essential, as irreversible parenchymal injury and structural complications such as cavitation or pneumothorax are rarely described in EVALI. Case Presentation A 47-year-old male road construction worker with daily vaping and marijuana use for two years presented with fever, dyspnea, and pleuritic chest pain. Imaging revealed diffuse bilateral ground-glass and patchy opacities concerning for multifocal pneumonia. Despite broad-spectrum antimicrobials, his hypoxia worsened, requiring ICU admission and intubation for bronchoscopy. Bronchoalveolar lavage grew Candida albicans but no bacterial pathogens; infectious, autoimmune, and vasculitic workups were negative. On hospital day two, CT angiography revealed acute bilateral pulmonary emboli, and anticoagulation was initiated. He developed acute respiratory distress syndrome (ARDS) and was managed with deep sedation, paralysis, prone positioning, and high-dose corticosteroids, with transient improvement. A repeat CT one month later demonstrated progression of bilateral infiltrates with evolving fibrotic interstitial changes and right-greater-than-left cavitary and cystic lesions. During steroid tapering, he suffered a large left spontaneous pneumothorax requiring chest tube insertion and doxycycline pleurodesis. After gradual improvement and completion of steroid taper, he was discharged to rehabilitation. Follow-up imaging showed partial resolution of ground-glass opacities but persistent fibrotic changes. Discussion This case highlights an uncommon fibrotic evolution of EVALI, complicated by cavitary transformation, pulmonary embolism, and spontaneous pneumothorax. While most EVALI cases demonstrate steroid-responsive, nonfibrotic injury, this patient’s course underscores the potential for chronic interstitial remodeling and cystic destruction, even with early corticosteroid therapy. Such atypical presentations suggest that repetitive or prolonged exposure to vaping aerosols, particularly in individuals with occupational particulate exposure, may trigger ongoing alveolar injury and dysregulated repair. Recognition of fibrotic or cavitary variants of EVALI expands the clinical spectrum of the disease and emphasizes the need for close radiographic follow-up and strict vaping cessation counseling. Conclusion EVALI may rarely progress to fibrotic interstitial lung disease with cavitary changes and pneumothorax. Awareness of these atypical manifestations is crucial for early identification, management, and prevention of irreversible lung injury. Repeat CT in 1 month showing progression with fibrotic pattern and RL cavitary lesions/cysts 1: Day 1 2. 1 month 3: pneumothorax 4. In 2 months This abstract is funded by: None
Obadare et al. (Fri,) studied this question.