Purpose or Case Report: Electronic cigarette (e-cigarette) or vaping product associated lung injury (EVALI) has become epidemic across the United States. To assist in prompt diagnosis, we describe the imaging features of adolescent EVALI.
Methods & Materials: A retrospective review of the electronic medical records of all patients treated for EVALI by the Texas Children’s Pulmonology service was performed to extract details of the product, clinical presentation, pulmonary function testing (PFT), treatment and outcome. An experienced pediatric chest radiologist categorized the chest radiographs (CXR) as normal or abnormal, and systematically noted the findings in the lungs, pleural spaces and mediastinum on computed tomography (CT) exams.
Results: The 9 patients (7M:2F) ranged in age from 14 to 18 years. Vaping products included nicotine, flavoring agents and cannabinoid oils. Eight patients reported co-existing use of marijuana, cigarettes or cocaine. Vaping ranged from “almost daily” to “20-30 puffs daily” for 3 weeks to 4 years. Presenting signs/symptoms included cough, chest tightness, dyspnea, fever, abdominal pain, vomiting, malaise, and weight loss.

CXR was abnormal in 8/9 at presentation. CT findings included diffuse ground-glass opacities (8/8), interlobular septal thickening (7/8), consolidation (6/8), mediastinal/hilar lymphadenopathy (6/8) and crazy-paving (6/8). Airspace opacities demonstrated subpleural sparing in 7/8. Two had pleural effusion and one had pulmonary nodules. The predominant pattern resembled diffuse alveolar damage, pulmonary hemorrhage, alveolar proteinosis, lipoid pneumonia or organizing pneumonia. EVALI was suggested in 2/9 radiology reports.

Bronchoalveolar lavage done in one showed neutrophils, hemosiderin-laden macrophages, and lymphocytes. Eight received PFTs, which showed obstructive pattern in 4 and restrictive pattern in 3. No lung biopsies were performed. No respiratory tract infections were identified. Seven were treated with steroids and one required intubation. Follow-up CXR improved in 4/6 patients over a period of up to 1 month. None underwent follow-up CT.
Conclusions: Chest CT findings characteristic of EVALI in adolescents include diffuse airspace opacities with subpleural sparing, interlobular septal thickening, crazy-paving and lymphadenopathy. A normal CXR is uncommon but does not exclude the diagnosis, and CXR can demonstrate response to steroids. With the rising popularity of vaping, radiologists should be aware of the imaging features of EVALI to expedite diagnosis.