E-Cig- or Vaping-Associated Lung Injury Presents With Diverse Radiological Findings

By WIll Boggs MD

January 31, 2020

NEW YORK (Reuters Health) - E-cigarette- or vaping-associated lung injury (EVALI) most commonly presents radiologically with an organizing pneumonia pattern, but a variety of findings has been reported.

"By suggesting the diagnosis of EVALI when one of the more common imaging patterns is encountered, the radiologist can alert the clinician to obtain a more detailed history in regards to vaping if not previously performed," said Dr. Seth Kligerman of the University of California, San Diego.

"Conversely, if an atypical imaging pattern is seen on CT or radiograph when a clinician suspects EVALI due to the clinical history, the radiologist can help steer the clinician away from the diagnosis," he told Reuters Health by email.

EVALI remains a diagnosis of exclusion, even among patients with a history of recent vaping, but chest imaging findings must be abnormal to suggest the diagnosis, Dr. Kligerman and colleagues note in Radiology.

The team reviewed the findings associated with EVALI, with a special focus on radiologic imaging by chest x-ray and chest CT, based on over 100 cases, Dr. Kligerman said.

Three injury patterns prevailed: 76% of cases showed organizing pneumonia, 48% showed acute fibrinous pneumonitis with organization, and 24% showed diffuse alveolar damage.

Centrilobular nodules are commonly found and likely reflect the distribution of injury in the bronchioles, whereas consolidation and ground-glass opacity that spare the lung periphery likely represent alveolar hemorrhage.

The authors also reviewed previously reported histologic features of EVALI, which commonly include foamy or vacuolated macrophages and pneumocytes, intraalveolar fibrin, bronchiolitis, bronchiolar mucosal ulceration, interstitial edema, and chronic interstitial inflammation.

"Although the imaging findings of EVALI overlap with other causes for similar patterns of acute lung injury, in the correct clinical context, radiologists can strongly suggest EVALI as a consideration," the authors conclude. "Therefore, when imaging findings suspicious for EVALI are found, direct communication with treating physicians is recommended to ensure that EVALI is considered as a potential diagnosis; this will help to ensure rapid diagnosis and the prompt institution of appropriate therapy."

"A detailed vaping history should be obtained on all patients," Dr. Kligerman said. "Although there is no definitive treatment for EVALI, the early and accurate diagnosis can allow for the rapid initiation of supportive care and the potential administration of corticosteroids."

"We still don't know the long-term consequences of having this lung injury," he said. "While a small percentage die and one patient has undergone lung transplant, many patients have severely damaged lungs that will likely lead to long-term pulmonary issues. Additionally, even in the cases that resolve, it wouldn't be surprising if this injury leads to some long-term deleterious effects to lung function."

SOURCE: https://bit.ly/36JslRL Radiology, online January 28, 2020.

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