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Diagnostic Radiology

Training Level

Resident PGY 2


Henry Ford Hospital


Purpose: E-cigarette, or vaping, product use associated lung injury (EVALI) is a newly recognized entity that is being reported with increasing frequency in the literature and mainstream press. The aim of this case report is to radiographically illustrate the fairly rapid progression of a severe case of EVALI that ultimately required a successful bilateral lung transplant, and to describe a unique histopathology correlation.

Case Report: Our patient is a 16-year-old, previously healthy male with a two year history of vaping who presented to an outside hospital for dyspnea and nonproductive cough. He was initially treated with antibiotics for community acquired pneumonia. Initial contrast-enhanced CT of the chest demonstrated subtle bilateral but right lower lobe predominant centrilobular nodules, ground glass opacities (GGO) and mild septal thickening. Bronchial alveolar lavage, microbiology studies and autoimmune panel were negative for an infectious or autoimmune etiology. Repeat chest CT only five days later following clinical deterioration demonstrated a dramatic worsening of bilateral nodular airspace opacities, septal thickening, GGO and dependent diffuse consolidations. Pneumomediastinum and mild bronchiectasis were also present. Our patient’s condition continued to decline requiring intubation and subsequent ECMO support. He was transferred to our tertiary care center for bilateral lung transplant. Histopathology of the explanted lungs described predominant acute necrotizing and granulomatous bronchopneumonia with areas of organizing pneumonia.

Discussion: The Centers for Disease Control and Prevention currently considers EVALI a diagnosis of exclusion with a confirmed case requiring the use of an e-cigarette 90 days before symptom onset, pulmonary infiltrates on chest imaging, absence of pulmonary infection and no other plausible diagnoses. Various imaging patterns of EVALI have been reported including hypersensitivity pneumonitis, diffuse alveolar hemorrhage, acute eosinophilic pneumonia and lipoid pneumonia, among others. This case demonstrates progression of a severe case of EVALI requiring bilateral lung transplant in an adolescent. Acute necrotizing and granulomatous bronchopneumonia were the predominant histologic features in our patient and have not previously been described in association with EVALI. It is important to consider EVALI in adolescents with a history of e-cigarette use who have a negative infectious and autoimmune work up presenting with severe respiratory symptoms and patterns of lung injury on chest imaging. As the popularity of these inhalational products evolves, radiologists must be informed of the emerging radiographic appearances of EVALI.

Presentation Date


Vaping Associated Lung Injury Requiring Bilateral Lung Transplant in an Adolescent