Electronic cigarette,or vaping,product use-associated lung injury (EVALI) in a patient with testicular cancer: A case report

Abstract

Electronic cigarette, or vaping, product use-associated lung injury (EVALI) is an increasingly recognized entity with the potential for severe pulmonary toxicity. We present the case of a young man first evaluated at a tertiary care center in the United States in 2019 with newly diagnosed testicular cancer with acute respiratory failure, which was initially attributed to possible metastatic disease but eventually determined to be related to EVALI. This case highlights the clinical features of EVALI, the potential diagnostic dilemma that can arise with EVALI when occurring in the setting of malignancy and the importance of inquiring about vaping use among patients with malignancy, especially in adolescents and young adults.

Introduction

Electronic cigarettes were first introduced in 2007, and their popularity has rapidly increased over the past decade. Their use has grown 5.5% among adults in North America and England. ¹ While there was initial interest in these products as a less harmful alternative to cigarettes, albeit with limited data to suggest a benefit in smoking cessation, a cluster of cases of lung injury associated with electronic cigarette use was first reported to the Centers for Disease Control (CDC) in August 2019. ² This entity, now known as electronic cigarette, or vaping, product use-associated lung injury (EVALI), resulted in 2602 hospitalized cases across the US and 57 deaths as of 9 January 2020. ³ Interestingly, there are no published cases of EVALI affecting patients with concurrent malignancy to our knowledge. As several malignancies occur in adolescents and young adults (AYA), the same population with increasing electronic cigarette use, this represents an important gap in the current literature.

Case description

We obtained written informed consent from the patient to proceed with publication of this case and associated images which were obtained from encounters in 2019 at a United States tertiary care center. We present the case of an 18-year-old man diagnosed with testicular cancer whose course was complicated by respiratory failure. He presented with a right testicular mass and underwent a radical inguinal orchiectomy which revealed a mixed germ cell tumor (teratoma [90%] and yolk sac tumor [10%]) with lymphovascular invasion (pT2). Computed tomography (CT) demonstrated a 5.7x6.2 cm retroperitoneal mass with no pulmonary findings and post-orchiectomy serum tumor markers included human chorionic gonadotropin (hCG) 27 mIU/mL (reference range [Ref]: < 3 mIU/mL), alpha-fetoprotein (AFP) 320 ng/mL (Ref: <8.3 ng/mL) and lactate dehydrogenase (LDH) 199 IU/L (Ref: 147-330 IU/L) consistent with stage IIC good risk testicular nonseminomatous germ cell tumor. Two weeks later, he presented with hypoxic respiratory failure and fevers. CT showed new bilateral ground-glass opacities and hilar adenopathy. Despite broad spectrum antibiotics, his respiratory status worsened requiring intubation and he was transferred to our hospital. Repeat CT again demonstrated bilateral ground-glass opacities, scattered air bronchograms and consolidation (shown in Figure 1). He had persistent fevers, required vasopressor support and developed oliguric renal failure. Infectious workup was negative including serial bacterial, fungal and acid-fast bacilli (AFB) blood cultures, respiratory viral panel, (human immunodeficiency virus (HIV), rapid plasma reagin (RPR), hepatitis C/hepatitis B viruses (HCV/HBV) reported legionella, histoplasmosis, tularemia, Brucella, cryptococcal and strongyloides. Bronchoscopy was negative for pathogens and cytology was negative for malignancy. Urine toxicology screen was positive for cannabinoids (⩾ 20 ng/mL). He was extubated after seven days and subsequently reported infrequent vaping of tetrahydrocannabinol (THC).

Figure 1.

Computed tomography axial chest lung window at level of trachea demonstrating bilateral ground-glass opacities and consolidation most pronounced posteriorly.

Due to his EVALI, our patient could not receive the first line treatment for his metastatic non-seminomatous germ cell tumor (NSGCT), that being bleomycin. After two cycles of etoposide and cisplatin (EP) chemotherapy he presented again with fever, dyspnea, and leukocytosis. CT demonstrated diffuse bilateral ground-glass opacities, lower lobe predominant bronchial wall thickening and mediastinal adenopathy. He received broad spectrum antibiotics, had a negative infectious workup and improved by day 3. At this time, he admitted to vaping THC three times daily. Inpatient psychiatry was consulted to assist with his substance abuse. He completed four cycles of EP chemotherapy followed by an uncomplicated retroperitoneal lymph node dissection with pathology revealing viable teratoma and no residual germ cell tumor.

Discussion/conclusion

Recent reports of EVALI reveal similar patterns in the clinical, laboratory, and radiologic findings as seen in our patient. In one review of 53 patients who reported vaping within 90 days of presentation, common findings included respiratory symptoms (i.e., shortness of breath, cough, or chest pain), subjective fever, leukocytosis, and bilateral ground-glass opacities on CT. ⁴

Although the mechanism of EVALI is not entirely understood, several reports suggest a potential role for Vitamin E acetate.^5-8 In our patient, bronchoalveolar lavage fluid was not available to test for Vitamin E acetate. With the rapid increase in vaping among AYA it is important to ask patients with testicular cancer and other AYA-associated malignancies about vaping and, specifically, THC use.^9,10

This patient’s acute onset respiratory failure after his recent cancer diagnosis, combined with his inability to provide a history due to intubation and sedation, presented a significant diagnostic dilemma. Although his metastatic testicular cancer diagnosis offered a tempting explanation for his respiratory failure, the clinical picture and CT scan findings were inconsistent. Metastatic testicular cancer involving the lungs typically manifests with pulmonary nodules and may rarely be associated with alveolar hemorrhage with acute respiratory distress syndrome in the setting of metastatic choriocarcinoma. Our patient subsequently fit the syndromic pattern of EVALI quite well, including his admission of THC use. This case therefore represents a clinical and diagnostic dilemma and reinforces the notion of taking a detailed social history in all patients, one which includes asking about the use of any e-cigarette products.