A Teen With Cough: Could This Be Vaping Related?

Susan Adkins, MD; Mark Layer, MD; Emily Koumans, MD


December 13, 2019

Editorial Collaboration

Medscape &

A complete confidential social history is obtained. John initially denies use of alcohol, tobacco cigarettes, and illicit drugs. Only after his mom leaves the room does he reluctantly admit to "vaping." On the basis of this revelation, the PCP determines that John is using e-cigarette, or vaping, products containing THC (tetrahydrocannabinol), the main psychoactive ingredient in marijuana. John reports to the PCP that he has used several brands of prefilled THC-containing e-liquid cartridges, or pods, nearly daily, and last used such products 1 day before the office visit.

Completion of EVALI Risk Assessment

Ideally, any patient with an influenza-like illness should be asked in a nonjudgmental and confidential manner about e-cigarette, or vaping, product use. Questions should include the following in order to assess exposure:

  • Types of substances used (eg, THC, cannabis [oil, dabs], nicotine);

  • Modification of products or addition of substances not intended by the manufacturer;

  • Product source, such as family, friends, a dispensary, or an online dealer;

  • Duration and frequency of use; and

  • Date of last use.

After discussion with John about his visit to his grandfather with influenza, his influenza-like symptoms, and his presentation within 48 hours of onset of symptoms, antiviral influenza therapy is initiated. Community-acquired pneumonia is not suspected, so antibiotics are not initiated.

One of the difficulties in diagnosing patients with EVALI is the nonspecific nature of the symptoms and that EVALI is a diagnosis of exclusion. To date, the most extensive description of the clinical presentation of patients with EVALI comes from a case series report. In that series of 53 patients meeting the confirmed case definition, patients presented with a mix of respiratory, gastrointestinal, and constitutional symptoms (Table).

Table. Symptoms Reported in Patients Meeting EVALI Case Definition

Symptoms at hospital presentation N = 53 (%)
Respiratory symptoms 98*
- Shortness of breath 87
- Cough 83
- Chest pain 55
Gastrointestinal symptoms  
- Nausea 70
- Vomiting 66
- Diarrhea 43
- Abdominal pain 43
Constitutional symptoms 100
- Subjective fever 81
- Fatigue or malaise 45
Vital signs  
- Tachycardia (heart rate > 100 beats/min) 64
- Tachypnea (respiratory rate > 20 breaths/min) 43
Oxygen saturation on room air  
- 89%-94% 38
- < 89% 31
*The one patient without respiratory symptoms had an oxygen saturation of 91% on room air.

John is young and appears well, has no significant comorbidities or hypoxia, has good social support, and is available for close follow-up in 24-48 hours. This makes him a reasonable candidate for outpatient empirical treatment of possible influenza and EVALI, according to CDC guidelines. Therefore, his PCP discusses marijuana use disorder and options for treatment, counsels him to immediately stop all use of e-cigarette or vaping products, and discharges him. He is instructed to watch for increasing difficulty in breathing, shortness of breath, inability to keep liquids down, and persistent fever, any of which should prompt an urgent return visit.

The Case Continues

John starts antiviral therapy and stops use of any vaping products. Despite this, he calls his PCP the next day and reports that he is experiencing progressive symptoms of dyspnea and pleuritic chest pain. Given his history of vaping, lack of improvement with antiviral therapy, and worsening symptoms, the PCP refers him to an emergency department (ED) for evaluation and calls the ED clinician to provide John's history.

Vital signs on presentation to the ED are as follows:

  • Temperature: 100.4° F (38° C)

  • Pulse: 115 beats/min

  • Blood pressure: 112/74 mm Hg

  • Respiratory rate: 24 breaths/min

  • Oxygen saturation: 93% on room air

Although John is exhibiting increased work of breathing, his lung examination is normal. His oxygen saturation decreases to 87% on room air with ambulation. A repeat chest x-ray is negative for infiltrate or other abnormal findings. Laboratory testing shows a leukocytosis of 19,000/mm3 with a neutrophilic predominance.

John is placed on supplemental oxygen after his oxygen saturation drops to 91% at rest. In the face of a worsening respiratory illness and a normal-appearing chest x-ray, CDC guidance indicates that a chest CT may be considered, as EVALI is a diagnosis of exclusion. John's chest CT demonstrates extensive diffuse bilateral ground glass opacities, a hallmark finding in many cases of EVALI.