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Key Features

Essentials of Diagnosis

  • Presentation is nonspecific

  • Illness is usually subacute

  • Respiratory, gastrointestinal, and constitutional symptoms are common

  • Tachycardia and tachypnea may also be present

General Considerations

  • No single causative agent has been identified

  • Most cases involve vaping products containing tetrahydrocannabinol (THC) or nicotine or both

  • Postulated factors contributing to the development of EVALI include

    • E-cigarette flavorings

    • Exposure to diacetyl (a popcorn flavoring that has been associated with lung injury)

    • THC

    • Adulteration of THC

    • Adulteration of delivery devices

    • Vitamin E acetate (used as a thickening agent)

  • Given the nonspecific nature of the presentation, especially during the influenza season and the COVID-19 pandemic, providers must have a high degree of clinical suspicion and ask patients specifically about vaping


  • An outbreak of EVALI began in the United States in 2019

  • Approximately 66% of patients have been male and 80% are under age 35

Clinical Findings

Symptoms and Signs

  • Respiratory symptoms (95%), including

    • Cough

    • Shortness of breath

    • Chest pain

  • Gastrointestinal symptoms (77%), including

    • Nausea

    • Vomiting

    • Diarrhea

  • Constitutional symptoms (85%), including

    • Fever

    • Chills

    • Weight loss

  • Tachycardia (55%) and tachypnea (45%)

  • Of note, 57% of cases have a recorded room air oxygen saturation of < 95%

Differential Diagnosis

  • Community-acquired pneumonia

  • COVID-19 (can be detected by reverse-transcription (RT)-PCR testing of respiratory tract secretions, ie, expectorated sputum, nasopharyngeal swab or bronchoalveolar lavage specimens)

  • Acute eosinophilic pneumonia

  • Acute respiratory distress syndrome

  • Hypersensitivity pneumonitis

  • Lipoid pneumonia

  • Organizing pneumonia

  • Influenza (can be detected by RT-PCR testing of respiratory tract secretions, including nasopharyngeal washings, in season)


Laboratory Findings

  • No laboratory findings are specific for diagnosis of EVALI

  • Leukocytosis

  • Elevated C-reactive protein

  • Elevated erythrocyte sedimentation rate


  • Chest radiograph typically shows bilateral pulmonary opacities

  • Chest CT scans are nonspecific and may show patterns seen in other disorders, such as

    • Hypersensitivity pneumonitis

    • Acute respiratory distress syndrome

    • Diffuse alveolar hemorrhage

    • Acute eosinophilic pneumonia

    • Lipoid pneumonia

    • Giant cell interstitial pneumonia

    • Cryptogenic organizing pneumonitis


  • Published case reports of hospitalized patients with EVALI have described rapid improvement following administration of corticosteroids



  • The natural progression of EVALI is not known

  • Over 95% of reported cases required hospitalization: 47% were admitted to intensive care, 22% were intubated and many died


Henry  TS  et al. Imaging findings of vaping-associated lung injury. AJR Am J Roentgenol. 2020;214:498.
[PubMed: 31593518]  
Jatlaoui  TC ...

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