Abstract Introduction E-cigarette or vaping use-associated lung injury (EVALI) is a diagnosis of exclusion characterized by acute lung injury in individuals with recent vaping history after infectious, cardiac, or neoplastic causes have been ruled out. Although uncommon overall, EVALI can present with severe hypoxemia and radiographic findings that mirror acute respiratory distress syndrome (ARDS), making timely recognition essential. Description of case: We present the case of a 37-year-old female with hypertension, polysubstance use, and a significant vaping history who presented with shortness of breath, cough, agitation, and hypoxia requiring intubation for airway protection. Labs were notable for leukocytosis (WBC 28.5 × 10³/µL) and normal renal function. Viral panels, MRSA nares screen, Legionella and Streptococcus urine antigens, and respiratory cultures were all negative. One of the blood cultures grew Staphylococcus epidermidis, considered a contaminant. The toxicology screen was positive only for opioids. Chest X-ray demonstrated bilateral air-space opacities, and CTA of the chest revealed diffuse ground-glass opacities with bilateral basal consolidation and subpleural sparing (Figure 1). No pulmonary embolism was identified. Based on her initial work-up, clinical suspicion was for multifocal pneumonia resulting in ARDS. Empiric antibiotics (vancomycin, ceftriaxone, and azithromycin) were started. Despite broad antimicrobial therapy, no infectious source was identified. The patient remained hemodynamically stable with oxygenation improving, and she was later extubated to a high-flow nasal canula. Repeat imaging continued to show an ARDS pattern without focal consolidation or effusion. With a negative infectious evaluation, a recent vaping history, and classic subpleural sparing, her presentation was most consistent with EVALI-associated ARDS. Steroids were not required, as the patient improved with supportive care alone, and antibiotics were discontinued once infection was excluded. She was discharged with counseling to stop vaping. Discussion EVALI remains a diagnostic challenge due to nonspecific symptoms and a presentation that overlaps with pneumonia and other common causes of acute hypoxic respiratory failure. Imaging patterns such as diffuse ground-glass opacities with subpleural sparing can help distinguish EVALI from typical ARDS or infectious pneumonia. Bronchoscopy offers limited diagnostic value, as lipid-laden macrophages are non-specific. Management is primarily supportive, including oxygen therapy, mechanical ventilation when necessary, and adjunct corticosteroids in selected patients. Diagnosis relies on a high index of clinical suspicion, exclusion of infectious causes, and an appropriate history. Our case reinforces the importance of considering EVALI in young patients with unexplained ARDS with negative infectious workup and highlights the need for early vaping cessation counseling to prevent recurrence. This abstract is funded by: None
Gonzalez et al. (Fri,) studied this question.
Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context: