CASE 17537 Published on 01.12.2021

E-cigarette or vaping product use associated lung injury (EVALI) in the immediate post-operative period


Chest imaging

Case Type

Clinical Cases


Bjorn Valgaeren, Elyn Van Snick, Jan Hendrickx, Bart Claikens

Department of Radiology, General Hospital Damiaan Ostend, Belgium


31 years, male

Area of Interest Lung, Respiratory system, Thorax ; Imaging Technique Conventional radiography, CT
Clinical History

A 31-year-old male underwent epigastric hernia repair under general anaesthesia without intra-operative complications. Minutes after extubation acute symptoms of dyspnoea, haemoptysis and thoracic discomfort developed with hypoxia (80% SpO2) and hypoxemia (64 mmHg pO2). Apart from regular use of e-cigarettes, the patient had been healthy before surgery. Pre-operative thoracic computed tomography (CT) scan was normal.

Imaging Findings

Pre-operative thoracic CT scan with intravenous contrast with axial reconstructions in lung window demonstrated no alveolar pathology. (Fig. 1)

Frontal supine thoracic x-ray in the recovery room showed symmetrical diffuse hazy alveolar opacities, most apparent in the dependent lung regions. (Fig. 2)

Shortly after the x-ray, a thoracic CT scan with intravenous contrast was performed. No lung embolism was seen. Axial reconstructions in lung window showed symmetrical diffuse centrilobular ground-glass attenuation most apparent in the upper pulmonary lobes and posterior in the lower pulmonary lobes. The ground glass opacities were suggestive for diffuse alveolar damage/haemorrhage considering the haemoptysis and acute onset. (Fig. 3)

Follow-up thoracic CT scan without intravenous contrast was performed two days later. Axial reconstructions in lung window showed important volume and density decrease of the ground glass opacities in all pulmonary lobes. (Fig. 4)



E-cigarette or vaping product use associated lung injury (EVALI) or vaping associated pulmonary injury (VAPI) are terms combining lung injury associated within 90 days after the last incidence of vaping or smoking tobacco or cannabis, without alternative diagnosis. [1] Pathophysiology is still unknown, but an association with alveolar tetrahydrocannabinol (THC), nicotine and vitamin E acetate has been found. [1-4] The majority of affected people were younger than 35 years of age. [5]

Clinical Perspective

Patients usually present with (sub)acute pneumonia-like symptoms like dyspnoea, tachypnoea, tachycardia, cough, chest pain, fever and sometimes haemoptysis. Gastrointestinal symptoms are often associated but are less prominent. Patients commonly progress to respiratory distress and sometimes death. [1]

Blood analysis, lung biopsy and bronchoalveolar lavage might be helpful ruling out other infectious, inflammatory or neoplastic pathology. Infectious pneumonia must always be ruled out. [1]

Imaging is useful in evaluating the extent of the lung injury, ruling out other more frequent pathology and in follow-up of disease evolution. [1, 6, 7]

Imaging Perspective

Thoracic x-ray is the first imaging step that shows diffuse bilateral hazy alveolar opacities or consolidations. In case of respiratory distress, thoracic high resolution computed tomography (HRCT) or lung embolism protocol in patients with risk factors are advised. [1, 6]

EVALI is a spectrum of lung injury like acute eosinophilic pneumonia, diffuse alveolar damage/haemorrhage, hypersensitivity pneumonitis, lipoid pneumonia and organizing pneumonia. [8, 9]

Diffuse bilateral ground-glass opacities and/or consolidations are the common main CT findings, sometimes with basilar dominance or subpleural sparing. [1, 6]


Almost all patients require hospital admission for supportive care. Most patients need oxygen supplementation and some need mechanical ventilation in severe cases of respiratory distress. [1]

Empiric antibiotic therapy is given to cover for (sur)infection. [1]

Systemic glucocorticoid therapy can be used in patients deteriorating under antibiotics and oxygen supplementation. [1]

The patient can be discharged from the hospital one to two days after resolution of symptoms, diminishing oxygen demand and decreasing imaging abnormalities. Short term clinical and radiological follow-up is advised until complete resolution. Cessation of smoking and vaping is critical to prevent relapse. [6, 7]

Take-Home Message / Teaching Points

Thorough anamnesis revealing (e-)cigarette use is the only way to make the right diagnosis. Consider EVALI in a history of smoking or vaping, diffuse bilateral alveolar opacities and no other alternative diagnosis in a patient with respiratory distress. Imaging is especially useful in ruling out other pathology, evaluating the extent of lung injury and follow-up.

Written informed patient consent for publication has been obtained.

Differential Diagnosis List
E-cigarette or vaping product use associated lung injury (EVALI)
Bacterial or viral pneumonia
Lung embolism
Granulomatous disease
Medication-induced lung injury
Acute respiratory distress syndrome (ARDS)
Final Diagnosis
E-cigarette or vaping product use associated lung injury (EVALI)
Case information
DOI: 10.35100/eurorad/case.17537
ISSN: 1563-4086