C59-06 I Smell You, I Puff You Not: Identifying Secondhand Vaping Exposure as a Potential Cause of Secondary Organizing Pneumonia

Abstract Introduction Organizing pneumonia (OP) is classified as cryptogenic (COP) if no etiology is identified or secondary when associated with underlying causes such as drugs, infections, autoimmune diseases, or malignancies. We report a patient with recurrent steroid responsive pneumonia and persistent infiltrates over years. A deeper dive into potential antigen exposures revealed secondhand vaping exposure as a probable trigger. Description A 30-year-old never-smoker female with a history of recurrent steroid-responsive pneumonia, Gilbert syndrome, pernicious anemia, and cold autoimmune hemolytic anemia, presented with acute hypoxemic respiratory failure. Imaging revealed extensive bilateral diffuse ground glass opacities and peri-bronchial infiltrates that waxed and waned over the past 6 years. Outpatient follow up was limited due to patient’s lack of insurance and resources. On each admission, a broad differential diagnosis was considered including COVID-19, vasculitis, diffuse alveolar hemorrhage, hypersensitivity pneumonitis, and OP. Extensive infectious and rheumatological workup was unremarkable on multiple occasions except for positive antinuclear antibody titer of 1:320. Transbronchial biopsy (TBBx) revealed normal lung parenchyma. Bronchoalveolar lavage (BAL) revealed a mixed pattern with 47% neutrophils, 17% lymphocytes, 14% macrophages, and 22% reactive mesothelial cells. Initial diagnosis was deemed to be COP, however, after repeated exposure history evaluation she was able to recall a family member vaping indoors frequently. Hospitalizations may have served as a form of exposure removal. She was advised to limit her exposure and maintain a symptom diary with no readmissions since. Our plan of action includes using a steroid-sparing agent and repeating autoimmune serologies. Discussion Diagnosis of OP is challenging given nonspecific symptoms and radiological patterns overlapping with other interstitial lung diseases (ILDs) including vaping use-associated lung injury (EVALI). TBBx is often nondiagnostic due to limited tissue sample size. A multidisciplinary approach is recommended. Persistent migratory opacities, resistance to antibiotic treatment, response to steroids, and lack of predominant eosinophilia in BAL, all confirm the suspicion of OP. Unlike EVALI, there is a paucity of reported detrimental effects of passive vaping, particularly in vulnerable populations like those with underlying pulmonary disease, children, and pregnant women. However, harmful effects of the aerosols generated - proven to alter lung protective mechanisms - cannot be ignored. Relapses are seen in steroid-resistant cases or with an unaddressed underlying etiology. Treatment includes using azathioprine, rituximab, cyclophosphamide or even azithromycin, although data is limited. Since ILDs often precede the onset of connective tissue disorders, serial serological testing for titers or seroconversion should be implemented during longitudinal surveillance. This abstract is funded by: None