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\begin{document}

\title{Hemoptysis in an Adolescent with EVALI}



\author[1]{Chelsea Reynolds}%
\author[1]{Heather Staples }%
\affil[1]{Prisma Health Children's Hospital-Midlands}%


\vspace{-1em}



  
  \date{May 26, 2024}


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\begin{abstract}
Vaping associated lung injury (EVALI) has increased in prevalence after
first being noted in an outbreak among teenagers in 2019. Vaping
involves the use of a heating device to aerosolize a product, typically
nicotine or more recently, cannabinoids. Products that contain
cannabinoids, such as CBD oil, are being used more as these products are
easy to obtain and are typically less expensive. The clinical
manifestations of EVALI are widespread and include respiratory symptoms
as well as cardiogenic, gastrointestinal, and constitutive symptoms.
EVALI rarely presents with hemoptysis as one of the main presenting
symptoms, especially in an adolescent. This case will discuss EVALI with
associated hemoptysis in a teenager secondary to vaping cannabinoid oil.%
\end{abstract}%



\sloppy


Hemoptysis in an Adolescent with EVALI

Chelsea Reynolds, DO, Heather M. Staples, MD

Prisma Health Children's Hospital- Midlands

No grants or financial reports were received for completion of this
case. No presentations have occurred nor have there been prior
submissions for case.

Prisma Health Children's Hospital- Midlands

Chelsea Reynolds, DO

9 Richland Medical Park Dr. Suite 200A Columbia, SC 29203

Phone: (864) 346-6720, Fax: (803) 434-6499

Chelsea.reynolds2@prismahealth.org

Keywords: EVALI, adolescent, hemoptysis

To the Editor,

Vaping associated lung injury (EVALI) has increased in prevalence after
first being noted in an outbreak among teenagers in 2019. Vaping
involves the use of a heating device to aerosolize a product, typically
nicotine or more recently, cannabinoids. Products that contain
cannabinoids, such as CBD oil, are being used more as these products are
easy to obtain and are typically less expensive. The clinical
manifestations of EVALI are widespread and include respiratory symptoms
as well as cardiogenic, gastrointestinal, and constitutive symptoms.
EVALI rarely presents with hemoptysis as one of the main presenting
symptoms, especially in an adolescent. This case will discuss EVALI with
associated hemoptysis in a teenager secondary to vaping cannabinoid oil.

Electronic cigarette use in teenagers is an increasing public health
concern that began after introduction of vaping in 2016 and later became
recognized as a public health crisis. In 2019, e-cigarette or vaping
product use--associated lung injury (EVALI) was recognized as a unique
disease entity. Individuals predominantly affected by EVALI are males
(66\%) who use tetrahydrocannabinol-containing (THC-containing) vapes
(82\%)\textsuperscript{1}. However, many EVALI patients report using
both nicotine and THC products (43\%)\textsuperscript{2,3}. EVALI
typically presents with a pneumonia-like illness, progressive dyspnea
and/or worsening hypoxemia, and does not usually include hemoptysis due
to diffuse alveolar hemorrhage (DAH). We describe an adolescent patient
with that developed DAH secondary to EVALI.

A 15-year-old Caucasian female with a history of anxiety, menorrhagia,
and obesity presented with two-week history of hemoptysis and chest
pain. She presented to urgent care multiple times for these symptoms and
was treated for pneumonia which was non-responsive to repeated doses of
antibiotic therapy. In the emergency department, chest x-ray was
concerning for bilateral pulmonary edema. After transfer to the
pediatric intensive care unit, repeat chest x-ray indicated bilateral
rounded airspace disease. CT angiography of the chest was negative for
pulmonary embolism but suggested a hypersensitivity reaction.
Echocardiogram was unremarkable and UDS was negative. Rheumatology,
hematology, and infectious disease workups were negative. Repeat CT
indicated ongoing effusions but improved compared to previous CT.
Hypersensitivity pneumonitis panel was obtained and negative.
Bronchoscopy and bronchoalveolar lavage were performed and visualization
revealed dilated submucosal capillaries. Results of the bronchoalveolar
lavage showed hemosiderin laden macrophages in the right middle lobe
indicative of DAH. It was later communicated that she vaped cannabinoid
oil prior to the onset of these symptoms. She had previously only
disclosed a history of daily nicotine vaping. This new information in
combination with DAH was suggestive of EVALI. She was discharged with a
course of oral corticosteroids and was sent home with resources to help
with the cessation of vaping. She followed up in the pediatric
pulmonology clinic the next week with resolution of symptoms and normal
spirometry.

Vaping induced lung injury or EVALI typically is reported in males with
presenting symptoms of worsening dyspnea and pneumonia like
illness\textsuperscript{4}. As of February 2020, the Centers for Disease
Control and Prevention reported a total of 2807 hospitalized EVALI cases
with 68 deaths.\textsuperscript{5} National and state data from patient
reports and product sample testing show tetrahydrocannabinol (THC)
containing e-cigarette, or vaping, products, played a major role in the
outbreak\textsuperscript{4}. Cannabidiol (CBD) oil has increased in
popularity as a vaping agent. CBD oil is a concentrated solvent extract
made from cannabis flowers or leaves. The flowers or leaves are
dissolved in an edible oil and the solvents that are used can vary from
organic solvents (ethanol, isopropyl alcohol) to harmful ones such as
petroleum or butane\textsuperscript{5}. CBD oil is not regulated by the
FDA and can have unregulated amounts of THC as well as other additives.
The association between vaping CBD oil and the lung injury it causes is
not known but there are many hypotheses to its etiology including
vitamin E acetate affecting alveolar surfactant, volatile chemical
production, and oils\textsuperscript{1}. Vitamin E acetate is a known
diluting agent and is known to cause severe inflammation in the
pulmonary parenchyma\textsuperscript{3}. Vitamin E acetate is thought to
be the main causative agent of changes seen in EVALI but that remains
undefined. The presentation with hemoptysis in this case is rare as only
11\% of EVALI cases have been reported with associated
hemoptysis\textsuperscript{5}.

The criteria used for a case definition of EVALI include: use of an
e-cigarette or related product within 90 days, lung opacities on chest
imaging, exclusion of lung infection, absence of alternative diagnosis
such as cardiac or neoplastic conditions\textsuperscript{4}. In this
case, the patient's lung imaging showed bilateral opacities and further
evaluation did not indicate pulmonary embolism or hypersensitivity
pneumonitis as a cause. Thorough workups with hematology, infectious
disease and rheumatology were negative. Her diagnosis was likely delayed
due to the history on admission of vaping only nicotine products and
only once the bronchoscopy was performed, was the history of vaping CBD
oil revealed. Her diagnosis of EVALI was supported with findings on
bronchoalveolar lavage that revealed hemosiderin laden macrophages with
negative cultures.

\textbf{Work Cited}

\begin{enumerate}
\tightlist
\item
  Alexander, L\ldots{}.Bellinghausen A, Eakin M. 2020. What are the
  mechanisms underlying vaping-induced lung injury. The Journal of
  Clinical Investigation. 130(6): 2754-2756.
\item
  Hazekamp A. 2018. The Trouble with CBD Oil. Med Cannabis Cannabinoids.
  (1) 65-72.
\item
  Rao D\ldots{}.Feng SY, Mittal V. 2020. Clinical Features of
  E-cigarette, or Vaping, Product Use--Associated Lung Injury in
  Teenagers. Pediatrics. 146(1): 1-12.
\item
  Belok S, Parikjh R, Bernardo J, Kathuria H. 2020. E-cigarette, or
  vaping, product use-associated lung injury: a review. Pneumonia.
  12:12.
\item
  Singh A, Tan Q, Saccone N, Linder D. A Case of Vaping TCH Oil Leading
  to Vaping Associated Pulmonary Injury: Our Approach to Its Diagnosis,
  Management, and Recommendations. Case Reports in Pulmonology
  {[}Internet{]}. 2020 Jan 05 {[}cited 2022 Jan 14{]}. Available from
  http://www.hindawi.com/journals/cripu/2020/6138083/
\end{enumerate}

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