CRA52 EVALI MASQUERADING AS SEPTIC SHOCK AND ARDS: A DIAGNOSTIC CHALLENGE IN DISTRICT HOSPITAL

YH Lim¹, SK Teoh¹, YW Cheah¹, NL Lai¹, JY Chan¹

¹Respiratory Unit, Hospital Ampang

Introduction
The rise in electronic cigarette (e-cigarette) use, particularly among younger individuals, has increased recognition of e-cigarette or vaping-associated lung injury (EVALI). Misconceptions that non-nicotine vaping is harmless have contributed to its prevalence. EVALI presentations range from mild respiratory symptoms to life-threatening respiratory failure, making early recognition essential.

Case Report
A 27-year-old male chronic smoker with bronchial asthma presented with fever, dyspnea, pleuritic chest pain, hemoptysis, vomiting and diarrhea. He arrived critically ill—hypotensive, tachypneic, and hypoxemic, requiring immediate mechanical ventilation, vasopressors, and intensive care. Initial chest X-ray revealed bilateral diffuse infiltrates, prompting a working diagnosis of septic shock secondary to pneumonia. However, subsequent investigations—including cultures, viral panels, atypical pneumonia screening, HIV testing, autoimmune markers and bronchoalveolar lavage—were all negative. Echocardiography showed global left ventricular hypokinesia. He developed acute kidney injury requiring intermittent dialysis. A follow-up chest CT demonstrated symmetrical perihilar consolidations, ground-glass opacities with subpleural sparing, and interlobular septal thickening. Given his recent vaping history and exclusion of other causes, EVALI was strongly suspected. Systemic corticosteroids were initiated, leading to rapid clinical improvement. He was eventually extubated and discharged home.

Conclusion
EVALI remains a diagnosis of exclusion, necessitating high clinical suspicion especially in young patients presenting with ARDS without clear etiology. Detailed history of vaping is crucial along with biomarkers such as procalcitonin to guide decisions in acute setting. Low procalcitonin may support non-infectious etiology, giving clinicians a “leeway” to initiate corticosteroids early. In this case, steroid led to dramatic improvement. Moving forward, we aim to enhance diagnostic certainty in highly suspicious cases by performing bronchoscopy with Oil-Red-O staining in ICU, which can detect lipid-laden macrophages—a hallmark of EVALI.