ALL THAT GLITTERS IS NOT GOLD

Covid-19 is known to affect the lungs and cause significant damage.  The description on CT scan is usually referred to as ground glass, a nonspecific finding but commonly associated with it. Being nonspecific, i.e. not pathognomic, is something we need to keep in mind as other conditions can present with the same finding. I had a very recent experience of a young white male who came to the hospital with complaints of dyspnea, low oxygen saturation and grossly abnormal CXR. In this climate, Covid-19 is the number one diagnosis. His rapid Covid-19 test was negative. His inflammatory markers such as ferritin, ldh, crp, d-dimer were all elevated. The clinical diagnosis was Covid-19 pneumonia; he was treated as such with the standard regimen of vitamins D, C, dexamethasone, zinc, oxygen, lovenox, azithromycin, ceftriaxone. The confirmatory test for Covid-19 came back negative. Undaunted, we repeated another confirmatory test and it also came back negative. As I was making rounds and discussing the case with the nurse, she casually mentioned that the patient uses vaping. A eureka moment occurred. I went back to talk to the patient, and he admitted to having a 10-year habit of doing so. The diagnosis shifted from Covid-19 pneumonia to a pneumoconiosis, a pneumonitis caused by exposure to environmental agents. A pulmonologist evaluated the patient and agreed with the diagnosis. His dexamethasone was changed to solumedrol. He finished his 1500mg cumulative dose of azithromycin, but the ceftriaxone was discontinued. Patient’s symptoms steadily but promptly improved. He never had any fever and his oxygen requirement quickly diminished.

The lung damage of vaping is a recently recognized entity1. It presents with findings identical to Covid-19 from a roentgen point of view. Certainly, with a pandemic associated with so many deaths and complications, we need to always make sure that Covid-19 is ruled in or out but it’s a reminder that in young patients, the use of vaping needs to be inquired about.

A good reference on this condition is from earlier in the year around the time of the onset of the epidemic by Layden2. It’s obvious that the appearance is identical to what we see in Covid-19.

 

It’s a reminder, in case we needed one, that all that glitters is not gold.

References:

  1.  Christiani, D. Vaping-induced Lung Injury. N Engl J Med 2020; 382:960-962 March 5, 2020.
  2. Layden, J et al. Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin. Final Report. N Engl J Med 2020; 382:903-916 March 5, 2020.

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