B26-15 A Second Hit: Recurrent Vaping-Associated Lung Injury Following Continued E-Cigarette Use

Abstract Introduction Electronic cigarette or vaping-associated lung injury (EVALI) is an acute, often severe respiratory illness first described in 2019. Diagnosis is clinical, supported by a history of vaping exposure, respiratory symptoms, characteristic imaging findings, and exclusion of alternative causes. Complete cessation from vaping is key to preventing recurrence. We present the case of a 40-year-old female with nicotine and marijuana vaping use who developed recurrent episodes of acute hypoxic respiratory failure attributed to EVALI. Case A 39-year-old woman with cannabis and e-cigarette use presented with acute onset dyspnea, chest pain, fever, and chills. CT chest showed diffuse bilateral groundglass opacities with interlobular septal thickening and relative sparing of the subpleural parenchyma. She developed worsening hypoxia requiring intubation and mechanical ventilation. Extensive infectious and rheumatologic workups were negative. She was treated with corticosteroids resulting in gradual recovery and discharge from the hospital, though she was unfortunately lost to follow-up afterwards. One year later she presented with recurrent symptoms and imaging findings, again requiring intubation and mechanical ventilation for hypoxia. Bronchoscopy with bronchoalveolar lavage showed neutrophil-predominance without evidence of infection. She was treated with corticosteroids with resolution of hypoxia. Repeat imaging showed significant interval improvement. She underwent thoracoscopy with wedge resection of the lingula. Pathology showed acute lung injury with septal thickening, organizing fibroblastic proliferation, and foamy pigmented macrophages consistent with the organizing phase of diffuse alveolar damage, secondary to EVALI. Discussion This case demonstrates recurrent EVALI with characteristic radiologic and histopathologic features, emphasizing the importance of early recognition, cessation counseling, and pulmonary follow-up to prevent recurrence. Radiographically, EVALI commonly shows bilateral groundglass opacities with subpleural sparing. The typical CT pattern resembles organizing pneumonia, though severe cases may demonstrate diffuse alveolar damage with consolidation, septal thickening, and fibrotic remodeling. Histopathologic findings often reveal organizing pneumonia or diffuse alveolar damage characterized by fibroblastic proliferation and foamy intra-alveolar macrophages. These features reflect a spectrum of acute lung injury that may evolve from inflammatory to fibrotic stages if exposure persists. Recurrent episodes of EVALI have been documented, particularly in patients who resume vaping following recovery. Adverse outcomes are associated with continued vaping, older age, and chronic cardiopulmonary disease. Management of recurrent cases mimics the initial treatment which includes supportive care, empiric antimicrobials until infection is excluded, and corticosteroids in severe cases. Sustained cessation of vaping remains essential, as ongoing use increases the risk of recurrent respiratory failure, persistent radiographic abnormalities, and long-term pulmonary dysfunction. This abstract is funded by: None