An Epidemic Supplanted by a Pandemic: Vaping-related Illness and COVID-19

Yoo Mee Shin, MD; Daniel P. Hunt, MD; Joyce Akwe, MD, MPH


South Med J. 2022;115(1):8-12. 

In This Article

Vaping and COVID-19

Hospitalizations for EVALI reached a peak in late 2019 and rapidly declined to extremely low numbers of reported cases by January 2020, just before the initial identification of COVID-19 cases in the United States.[47] Although vaping-related illness may have nearly disappeared as a consequence of increased public awareness resulting in risk reduction by users and by removal of vitamin E acetate from vaping products, a case report of a patient in April 2020 reminds clinicians that EVALI should remain in the differential diagnosis for young patients admitted with severe lung injury.[48] Presenting symptoms of EVALI (dyspnea, cough, fever, nausea, vomiting, and diarrhea) overlap with those of COVID-19,[36,49,50] and during population surges of the pandemic there is a tendency to narrow diagnostic considerations. As noted previously, EVALI is considered a diagnosis of exclusion, particularly exclusion of infectious etiologies, but critical to making the diagnosis is asking patients about vaping exposures.

Similar to clinical presentation, imaging findings for EVALI and COVID-19 demonstrate significant overlap.[51] Chest radiography in EVALI typically shows bilateral multifocal ground glass opacities or symmetric consolidation with lower lung zone predominance. Similarly, in COVID-19 the chest X-ray may initially appear normal, although typical findings include patchy bilateral ground glass opacities and/or consolidation that is peripheral and lower lung predominant. Chest CT in EVALI typically demonstrates bilateral symmetric ground glass opacities with or without consolidation predominantly in the lower lobes with subpleural sparing. Chest CT in COVID-19 shows similar findings, although peripheral and subpleural distribution is common. Subpleural sparing should prompt consideration of EVALI instead of COVID-19.[52]

Other potentially useful clues to EVALI include leukocytosis versus normal or low white blood cell count with associated lymphopenia seen with COVID-19.[53] Some authors have suggested that rapid response to corticosteroids also may favor EVALI in young patients with extensive lung findings.[53]

An online survey of 4351 adolescents and young adults (ages 13–24) reported an increased risk of self-reported COVID-19 illness among users of e-cigarettes.[54] This study received substantial attention in the media but also was criticized for methodologic flaws. Although convincing evidence is lacking, it seems plausible that e-cigarette usage would increase the risk of severe COVID-19 lung injury and may increase susceptibility to the infection.