대한흉부영상의학회 Weekly Chest Cases

Case No : 1196 Date 2020-09-27

Courtesy of Seulgi You, Joo Sung Sun, Kyung Joo Park / Ajou University School of Medicine
Age/Sex 32 / M
Chief ComplaintFever and general weakness for 3 days

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Diagnosis With Brief Discussion

Diagnosis: EVALI (E-cigarette or Vaping product use-Associated Lung Injury)
Radiologic Findings: Fig 1. Chest PA shows diffuse GGO in both lungs.
Fig 2-5. Chest CT scans show diffuse GGOs in both lungs with subpleural sparing.
Brief Review: The patient manifested with fever and general weakness for 3 days. He has started the usage of E-cigarette 4 months ago and he changed his E-cigarette 3 months ago (uncertain vape products). After changing his E-cigarette, he has had symptoms of mild dyspnea. Laboratory evaluation demonstrated mild leukocytosis with a neutrophilic predominance. There was no evidence of infection on viral panel test, specimen Ag tests, blood culture and bronchoalveolar lavage. Furthermore, there was no abnormality on test of rheumatologic disease. After exclusion of other plausible diagnoses, he diagnosed with EVALI.
EVALI (E-cigarette or Vaping product use-Associated Lung Injury) is an acute or subacute pulmonary injury induced by inhaling an aerosol that is created by heating vape products. The E-cigarettes users inhale variable substances, including nicotine, flavors, tetrahydrocannabinol (THC), and cannabidiol (CBD), in aerosol form. These aerosols induced edema of airways with epithelial sloughing, alveolar inflammation, and edema with hypoxemia. The EVALI is more common in person who used vaping products containing THC and/or vitamin E acetate. However, other additives including nicotine, CBD, coconut oil and limonene might be involved in lung injury.
The clinical manifestation of the EVALI is nonspecific, including respiratory (cough, shortness of breath, chest pain), gastrointestinal (abdominal pain, diarrhea), and constitutional symptoms (fever, fatigue). The EVALI is a diagnosis of exclusion; the patient must elicit a history of recent E-cigarette use, other possible etiologies must be eliminated (e.g., infection, other drug or exposure, connective tissue disease, and so on), and chest imaging findings must be abnormal.
The majority of patients show diffuse hazy or consolidative opacities on chest radiographs, The most common CT finding is basilar-predominant consolidation with ground-glass opacity and lobular or subpleural sparing. Furthermore, chest CT findings reveal heterogeneity of pathologic patterns of lung injury including organizing pneumonia (OP), diffuse alveolar damage (DAD), hypersensitivity pneumonitis (HP), diffuse alveolar hemorrhage, acute eosinophilic pneumonia (AEP), exogenous lipoid pneumonia, giant cell interstitial pneumonia (GIP) and respiratory bronchiolitis.
Systemic corticosteroid is used for the treatment of EVALI but the efficacy has not been studied.
References: 1. Kligerman S et al., Radiologic, Pathologic, Clinical, and Physiologic Findings of Electronic Cigarette or Vaping Product Use-associated Lung Injury (EVALI): Evolving Knowledge and Remaining Questions. Radiology. 2020 Mar;294(3):491-505.
2. Travis S et al., Imaging Findings of Vaping-Associated Lung Injury, American Journal of Roentgenology, 2020; 214:498
Keywords: lung, inhalational lung injury, E-cigarette, vaping product,

No. of Applicants : 60

▶ Correct Answer : 8/60, 13.3%

- Mayo Clinic , United States AKITOSHI INOUE
- CH de la Cote Basque , France PAUL ARDILOUZE
- University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
- Chonbuk National University Hospital , Korea (South) KUM JU CHAE
- Asan Medical Center , Korea (South) JIHOON KIM
- Kitano Hospital , Japan SATOSHI IKEDA
- Ichinomiya Nishi Hospital , Japan Takao Kiguchi
- Private sector , Greece VASILIOS TZILAS

▶ Correct Answer as Differential Diagnosis : 14/60, 23.3%

- TWMU Medical Center East , Japan MASAFUMI KAIUME
- McGill University Health Center , Canada Alexandre Semionov
- Tiger Gate Hospital , Japan SHIN-ICHI CHO
- Hamamatsu University Hospital , Japan HAYATO NOZAWA
- National Center for Global Health and Medicine , Japan MASATOSHI HOTTA
- Yeungnam University Medical Center , Korea (South) JONGSOO PARK
- Gifu University Hospital , Japan Yo Kaneko
- The University of Tokyo Hospital , Japan RYO KUROKAWA
- Mayo Clinic , Japan HIROAKI TAKAHASHI
- Osaka City General Hospital , Japan SHU MATSUSHITA
- Diskapi Yildirim Beyazit Hospital, Ankara , Turkey MERIC TUZUN
- Ajou University Hospital , Korea (South) HYERIN KIM
- University of Tsukuba Hospital , Japan SODAI HOSHIAI
- Hamamatsu University Hospital , Japan YUKI HAYASHI

▶ Semi-Correct Answer : 25/60, 41.7%

- Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
- , Japan HIROAKI ARAKAWA
- ZIGONG TCM HOSPITAL OF CHINA , China Cao Cunyou
- Showa University Fujigaoka Hospital , Japan KYOKO NAGAI
- NIMS, HYDERABAD , India BHASKAR K
- IRSA LA ROCHELLE , France JEAN LUC BIGOT
- The University of Tokyo Hospital , Japan MOTO NAKAYA
- Ichinomiya Nishi Hospital , Japan CHIHIRO KIGUCHI
- Asan Medical Center , Korea (South) EUNJI CHOI
- DELTA CARE HOSPITAL, THANJAVUR, INDIA , India SIVARAJA SUBRAMANIAM
- Cabinet Capricorne, clinique sainte-clotilde , Reunion FABIEN HO
- The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
- Chungbuk National University Hospital , Korea (South) JUNGHWAN KIM
- Soonchunhyang University Hospital Bucheon , Korea (South) SEONGHWAN BYUN
- Other , Korea (South) MINSU KIM
- Eskisehir Sehir Hastanesi , Turkey MURAT SAHIN
- , Japan HIROAKI ARAKAWA
- Other , Korea (South) KYU-CHONG LEE
- Fortis hospital , Mohali , India SHALEEN RANA
- Post graduate , India SHASHI KUMAR ANBAZHAGAN
- National Center for Global Health and Medicine , Japan HIROSHI TAKUMIDA
- , Japan KAZUMA TERAUCHI
- , Japan YUMI MAEHARA
- Diagnose.me (BV) / Royal Perth Hospital , Australia YURANGA WEERAKKODY
- Jiangsu province hospital , China WANGJIAN ZHA

대한흉부영상의학회 Korean Society of Thoracic Radiology

Cases by Disease Category

Case No : 1196 Date 2020-09-27

Discussion

No. of Applicants : 60