What question did this study set out to answer?

To report a rare case of secondary pulmonary alveolar proteinosis resulting from chronic vaping.

May 20, 2026

B26-17 Secondary PAP From Chronic Vaping: A Severe EVALI Variant Requiring Bilateral Lung Transplant

Key Points

To report a rare case of secondary pulmonary alveolar proteinosis resulting from chronic vaping.
Patient with a 9-year history of daily nicotine vaping and cannabis inhalation admitted with severe respiratory symptoms.
Diagnosis confirmed via chest CT, BAL findings, and lung biopsy, excluding autoimmune factors.
Management included cessation of vaping, corticosteroids, and inhaled GM-CSF.
Patient progressed to respiratory failure despite aggressive treatment, requiring high-flow oxygen (FiO2 70%).
Bilateral lung transplantation was necessary due to disease severity and lack of response to standard therapies.
Case emphasizes the need for clinicians to consider PAP in young patients with vaping history and respiratory issues.

Abstract

Abstract Introduction Pulmonary alveolar proteinosis (PAP) is a rare lung disease characterized by the accumulation of surfactant-derived lipoproteinaceous material within the alveoli, resulting in impaired gas exchange. While most cases are autoimmune, caused by anti-GM-CSF antibodies, secondary PAP results from macrophage dysfunction due to malignancy, infection, or inhalational toxins. E-cigarette or vaping product use-associated lung injury (EVALI) is an emerging clinical entity, but its potential to trigger secondary PAP remains poorly defined. We report a unique, treatment resistant case of vaping-induced secondary PAP, expanding the clinical spectrum of EVALI. Description A 28-year-old male with a 9-year history of daily nicotine vaping and frequent cannabis wax inhalation presented with progressive exertional dyspnea, hypoxemia, and digital clubbing. Chest CT showed diffuse ground-glass opacities and interlobular septal thickening, characteristic of the classic “crazy paving” pattern. BAL revealed PAS-positive lipoproteinaceous material, and lung biopsy confirmed intra-alveolar surfactant accumulation and foamy macrophages, consistent with PAP. Negative anti-GM-CSF antibodies excluded autoimmune PAP. Despite vaping cessation and aggressive management, including 5 months of systemic corticosteroids, a 7-day trial of inhaled GM-CSF (sargramostim), and empiric antibiotics, his condition progressed to respiratory failure requiring high-flow oxygen (FiO2 70%). Whole-lung lavage was deferred due to refractory hypoxemia. Ultimately, he underwent bilateral lung transplantation, highlighting the profound severity and irreversible nature of the disease. Discussion This case underscores an urgent public health concern as vaping use surges among young adults. Chronic inhalation of nicotine and cannabis aerosols may result in irreversible alveolar macrophage dysfunction, culminating in secondary PAP. The patient’s lack of response to standard therapies and progression to end-stage respiratory failure emphasizes the seriousness of vaping-related lung injury. Clinicians should maintain a high index of suspicion for PAP in young patients with unexplained respiratory symptoms and a history of vaping. Public health efforts must prioritize regulation and education to reduce vaping-related lung disease. This abstract is funded by: None

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B26-17 Secondary PAP From Chronic Vaping: A Severe EVALI Variant Requiring Bilateral Lung Transplant

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