E-cigarette/vaping associated lung injury: an ongoing public health crisis.

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Learn more: PMC Disclaimer | PMC Copyright Notice BMJ Case Rep . 2026 May 28;19(5):e272481. doi: 10.1136/bcr-2026-272481 E-cigarette/vaping associated lung injury: an ongoing public health crisis Victor Del Rio 1, ✉ , Andrew Treihaft 1 , Jeremy A Weingarten 2 , Anthony Saleh 2 , Ruth Minkin 2 , Laurne Groner 3 , Stephen Peterson 4 Author information Article notes Copyright and License information 1 Internal Medicine, NewYork - Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York, USA 2 Pulmonary and Critical Care Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York, USA 3 Radiology, Weill Cornell Medicine Department of Radiology, New York, New York, USA 4 Internal Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital, New York, New York, USA None declared. ✉ Dr Victor Del Rio; delrio.r.victor@gmail.com Received 2026 Jan 29; Accepted 2026 May 4; Collection date 2026. Copyright © BMJ Publishing Group Limited 2026. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group. This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/licenses/by-nc/4.0/ . PMC Copyright notice PMCID: PMC13223391  PMID: 42209039 Summary E-cigarette or vaping-associated lung injury (EVALI) remains an important but often overlooked cause of acute respiratory failure, particularly in the years following the COVID-19 pandemic. We describe a middle-aged woman with a recent history of nicotine-only vaping who presented with worsening cough, dyspnoea on exertion and progressive hypoxia. Imaging initially suggested multifocal pneumonia, and she was started on broad-spectrum antibiotics and bronchodilator therapy. Despite this, she continued to deteriorate, prompting intensive care unit transfer and initiation of high-dose corticosteroids. Extensive workup including infectious, autoimmune and vasculitis panels was negative. Given her history of recent vaping, EVALI was considered the most likely aetiology. Her clinical course improved significantly after corticosteroid therapy, and she was discharged on a steroid taper. This case highlights the diagnostic challenges posed by EVALI and the ongoing risk associated with vaping, including those containing only nicotine. This case report aims to contribute to the ongoing clinical awareness of EVALI. Keywords: Medical management, Public health, Respiratory medicine, Drugs: respiratory system, Tobacco related disease Background In the summer of 2019, cases of a novel lung injury pattern thought to be related to inhalational injury presented, resulting in various clinical manifestations. Epidemiological inquiry determined that this injury was due to e-cigarette/vaping use. 1 E-cigarettes/vapes are marketed as a safe alternative to combustible tobacco products and have gained increased popularity, especially among teenagers and young adults. In 2023, approximately 6.5% of US adults reported using e-cigarettes, with a steady rise from 3.7% in 2020 following an initial decline. 1 The use of e-cigarettes in younger individuals remains the most commonly used tobacco product, with 7.8% of high school students and 3.5% of middle school students reporting current use in 2024, according to Centers for Disease Control and Prevention (CDC) survey data. 1 With this increased use, there was a national outbreak of e-cigarette/vaping product use-associated lung injury (EVALI) emerging in 2019. By January 2020, there were 2668 cases of EVALI reported across the USA, with 68 confirmed deaths. Most affected individuals were under 35 years (76%), with a median age of 24 years, and 66% were male. 2 3 Many patients (82%) reported the use of tetrahydrocannabinol (THC)-containing products, and 94% of bronchoalveolar lavage (BAL) fluid samples collected during the outbreak demonstrated a lipid additive vitamin E-acetate (VEA). While VEA is generally used as a topical agent, its presence in vaporising products and the chemical alterations caused by superheating have not been adequately studied; despite this, it has been used as an additive to dilute the THC in e-cigarettes/vapes. 2 3 A lesser discussed yet also prevalent agent is medium chain triglycerides (MCT), present in almost 20% of studied vaping cartridges. 4 MCT was historically used as a nutraceutical oil due to its health benefits as a replacement for traditional oils in cooking. 5 Its addition to vaping mixtures is similar to VEA since it helps dilute or concentrate the mixtures and acts as a medium to aerosolise the liquid. 6 This process, much like with VEA, also has the potential to result in lung injury from its interaction with pulmonary surfactant, although, like VEA, the exact process requires further study. 6 Currently, the CDC and FDA warn against the use of any THC e-cigarette products with VEA and of the potential dangers of MCTs. 4 Additionally, while the risk may not be as high, conventional nicotine-containing products (without THC) have also been reported to cause vaping associated acute lung injury (EVALI). EVALI may be challenging to diagnose because of its non-specific symptoms, overlap with infectious and inflammatory lung diseases and its rapidly progressive nature. Radiological and histopathological findings usually include bilateral ground-glass opacities and organising pneumonia patterns, further complicating timely recognition. 7 8 Although the CDC discontinued national case tracking in February 2020 due to the COVID-19 pandemic, the risk persists, particularly given continued vaping trends and ongoing availability of unregulated THC products. 1 Case presentation A middle-aged female with a 5 pack-year smoking history (quit 4 months prior to admission) and active nicotine vaping (started 3 months prior with escalating daily use) presented with worsening cough, congestion and dyspnoea on exertion. On arrival at the emergency department, she was hypoxic, tachycardic and in respiratory distress. She was placed on non-rebreather oxygen supplementation without significant improvement in respiratory status. She had exposure to sick contacts, but the outpatient workup was negative for viral infection. Admission workup included blood cultures (negative), procalcitonin (0.86 ng/mL), Methicillin-resistant Staphylococcus aureus (MRSA) nares swab (negative) and respiratory viral and bacterial swab (positive for Mycoplasma DNA), with reflex antibody titers showing mildly elevated Immunoglobulin (Ig) (0.37 U/L) and normal IgM (0.06 U/L), with a chest X-ray ( figure 1 ) showing multifocal pneumonia. She was initiated on ceftriaxone, azithromycin, albuterol and ipratropium nebulisers every 6 hours. We admitted her to the respiratory unit for close respiratory monitoring, initiation of methylprednisolone 40 mg every 8 hours and high-flow nasal cannula (HFNC). Despite the high-flow oxygen therapy, she continued to experience hypoxia and ongoing respiratory distress. CT chest obtained on day 3 ( figure 2 ) revealed bilateral multilobular lung opacification with a density in the right upper lobe and tree-in-bud opacities in the left lower lobe. In addition, her oxygen supplementation progressed to maximum settings on HFNC despite her antibiotic and steroid regimen. Additional blood work obtained revealed elevated C reactive protein of 188 mg/L and erythrocyte sedimentation rate of 90 mm/hour. Her worsening clinical picture and high risk for intubation her antibiotics were broadened to cefepime and vancomycin in addition to the azithromycin and she was transferred to the medical intensive care unit for closer monitoring. Given her endorsement of vape use further history was obtained, she reported recent escalation of her vaping use due to personal stressors. She reported the vape was nicotine only and bought at a convenience store but was unable to provide it as she had already discarded it before coming into the hospital. Due to concern for EVALI, methylprednisolone 1000 mg was added and high-flow nasal mask over the cannula was initiated to provide additional respiratory support. On day 4, she successfully weaned off the high-flow mask with slow weaning from the high-flow support to a conventional nasal cannula on day 8. Connective tissue, autoimmune, vasculitis and additional infectious studies were negative. On day 8, she was transferred to the general medical ward on a nasal cannula and a steroid taper, where she remained for 4 days of physical therapy. She was discharged after a total of 12 days and discharged on a 6-day prednisone taper to follow-up with the pulmonary department. Figure 1. Chest radiographs on presentation demonstrate diffuse lung disease, characterised by bilateral hazy and consolidative opacities, most pronounced in the left lung. Open in a new tab Figure 2. Anteroposterior chest radiograph (left) and non-contrast chest CT (right) were obtained 1 day prior. Anteroposterior chest radiograph shows increased diffuse bilateral hazy and consolidative opacities. Axial chest CT image demonstrates respiratory motion artefact due to profound dyspnoea and bilateral consolidation, ground glass opacities, nodular opacities (dashed arrow), and perilobular opacities (solid arrows). CT pattern is suggestive of acute lung injury and organising pneumonia. Open in a new tab Investigations On arrival, due to hypoxia, respiratory distress and tachycardia, the initial workup consisted of blood work, chest radiograph and viral and bacterial nasal swab. The workup for typical bacterial pathogens was negative on cultures. However, mycoplasma PCR was positive with a negative IgM and positive IgG. This could indicate past exposure with colonisation which has been reported in adult and paediatric populations. 9 10 This could also indicate early reinfection, and there have been case reports of mycoplasma being implicated in the pathogenesis of EVALI. 11 Because EVALI is a diagnosis of exclusion a comprehensive rheumatological evaluation was performed along with a transthoracic echocardiogram to rule out alternative aetiologies, all of which were normal ( table 1 ). These negative findings coupled with personal history of recent vaping led to our diagnosis of EVALI. Table 1. Infectious, inflammatory and rheumatological workup obtained prior to arriving at EVALI diagnosis. Workup obtained prior to diagnosing EVALI Infectious causes Alternative causes Blood cultures x 2 (negative) MRSA nares swab (negative) Respiratory culture with Gram stain (negative) Viral and bacterial nasal swab (positive for mycoplasma DNA) Mycoplasma serology: IgG 0.37 U/L (elevated), IgM 0.06 U/L Procalcitonin: 0.86 ng/mL HIV ½ AB: non-reactive HIV 1 P24 AG: non-reactive Legionella pneumophilia AG: negative ESR: 188 mg/L CRP: 90 mm/hour DSDNA: 1 IU Centromere AB: 1 AU/mL SSA AB IgG: 2 AU/mL SSB AB IgG: 1 AU/mL SCL-70 AB: 0 AU/mL Smith AB IgG: 4 U Myeloperoxidase AB: 0 AU/mL Proteinase 3 IgG: 0 AU/mL Cyclic citrullinated peptide: 3 units Rheumatoid factor: 24 IU/mL (elevated) JO-1 IgG: 1 AU/mL ANA IgG: none detected Total complement: 51.9 U/mL C3: 141 mg/dL C4: 23 mg/dL Open in a new tab ANA, Antinuclear antibody; CRP, C reactive protein; DSDNA, double stranded DNA; ESR, Erythrocyte Sedimentation Rate; EVALI, e-cigarette/vaping product use-associated lung injury; HIV, Human Immunodeficiency Virus; Ig, Immunoglobulin; MRSA, Methicillin-resistant Staphylococcus aureus. Differential diagnosis The patient’s presentation of progressive dyspnoea, cough, hypoxaemia and imaging findings were consistent with multifocal pneumonia. This was supported by a positive mycoplasma DNA on nasal swab; however, her rapid decompensation despite appropriate antibiotic coverage made this differential less likely. Other diagnoses such as community-acquired pneumonia including COVID-19, organising pneumonia, hypersensitivity pneumonitis, connective tissue disease-associated interstitial lung disease, alveolar haemorrhage, vasculitis and EVALI. Given the patient’s active vaping history, lack of clinical improvement with empiric antimicrobials and absence of an alternative unifying diagnosis, EVALI emerged as the most plausible aetiology. According to CDC case definitions, a probable diagnosis of EVALI requires recent use of e-cigarette or vaping products within 90 days, pulmonary infiltrates on imaging and exclusion of infectious or alternative causes—criteria met in this case, particularly in the context of profound hypoxemia and rapid respiratory decline. 1 This case mimics many published cases of EVALI. EVALI patients are typically young and healthy; however, some cases have affected adults over the age of 40 years. In 2019, the median age for patients was 24 years; reported cases ranged from 13 years to 85 years. 1 This patient presented bilateral pulmonary infiltrates, elevated oxygen requirements and radiographic features commonly reported in EVALI, including tree-in-bud opacities and multilobular infiltrates. 7 Her infectious and autoimmune workup was unrevealing, just as in so many cases prior. Interestingly, unlike most EVALI patients who reported THC use, this patient’s exposure history focused on nicotine-based vaping, reinforcing that EVALI is not exclusive to THC-containing products. 1 Unfortunately, she was unable to provide the exact e-cigarette she had been using, and her tenuous respiratory status excluded diagnostic BAL and transbronchial biopsy. Treatment As EVALI remains a poorly understood pathology there exist no clear guideline or standard of management for presenting cases. As with this patient, the initial goal was to stabilise the respiratory status through oxygen supplementation and discover the underlying cause. The use of antibiotics as further explored in the discussion session is key while patients are worked up to ensure that infections are truly ruled out or managed if also present. Her initial positive mycoplasma PCR and radiographic findings indicated the use of antibiotics which were broadened when her respiratory function continued to deteriorate. The use of steroids is another matter of discussion, as no dosage or regimen plan has been studied for efficacy, for this case given the severity of presentation pulse (1000 mg) dose of methylprednisolone for 3 days was used, with an additional taper regimen that lasted past her discharge as mentioned above. In addition to steroids and antibiotics further support was provided using nebulised albuterol and ipratropium for bronchodilator support and she was discharged on triple inhaler therapy consisting of an inhaled corticosteroid, long-acting beta agonist and long-acting muscarinic agonist with an as needed rescue albuterol inhaler. Outcome and follow-up 1 month after discharge, she was seen in the outpatient pulmonology office with continued improvement in respiratory status and completion of her steroid taper. Her dyspnoea is ongoing and requires supplemental oxygenation of 2–3 L nasal cannula when exerting herself. She still required triple inhaler therapy with inhaled corticosteroid, long-acting beta agonist and long-acting muscarinic agonist in addition to her rescue inhaler. The initial visit workup included repeat of her CT chest, referral for pulmonary function tests and regular pulmonology follow-up to which she is adherent. Discussion EVALI is a diagnosis of exclusion that remains incompletely understood. Histopathological findings from lung biopsies and autopsies commonly reveal varying patterns of acute lung injury, including diffuse alveolar damage (DAD), organising pneumonia and lipid-laden macrophages. 8 The injury to the lungs is believed to be secondary to several agents found in vaping cartridges, including VEA, THC and MCT. VEA is an additive frequently found in illicit THC-containing vape products; traditionally, it is a lipid-soluble substance that is used in many supplements and cosmetics. 6 When exposed to high temperatures, such as in vaping devices, it can disrupt pulmonary surfactant, impair gas exchange and generate toxic byproducts such as ketene gas, as diagrammed in figure 3 . This leads to alveolar injury, inflammation and characteristic histological findings such as DAD and lipid-laden macrophages. 12 MCTs initially saw their use as a food alternative to traditional cooking oils, which was also introduced much like VEA to alter the concentration of vaping liquids. The resulting pulmonary toxicity also shares many of the same processes as VEA, with the added impact on the viscosity and elasticity of pulmonary surfactant, although that also remains under study. 6 13 Figure 3. EVALI proposed pathophysiology. Vitamin E acetate activates the macrophages and initiates oxidative stress, damaging alveoli and causing capillary leak oedema. The result is severe hypoxia. Created in https://BioRender.com by Andrew M. Treihaft. Open in a new tab Management of EVALI requires a multidisciplinary approach. Early recognition and exclusion of other causes of acute lung injury is necessary due to EVALI having a non-specific presentation and possible overlap with infectious and inflammatory pulmonary diseases ( figure 4 ). Approximately 50% of patients may have gastrointestinal symptoms and pulmonary findings. Initial management involves broad-spectrum antibiotics and supportive oxygenation management techniques such as supplemental oxygen and bronchodilators as required. 1 14 Bacterial or atypical pneumonia is covered by broad-spectrum antibiotics, which may coexist or be initially suspected based on clinical features and imaging. 14 Systemic corticosteroids are the mainstay treatment for EVALI, although no definitive dose exists to initiate management. Typically, patients are administered methylprednisolone intravenously or high-dose prednisone orally, with expected improvement within 24–72 hours post administration. 1 14 A provider may use ‘pulse dose’ steroids such as methylprednisolone 500–1000 mg/day, typically reserved for refractory cases. 9 15 Figure 4. Flowchart for diagnostic evaluation of EVALI. Created in MS Paint by Victor Del Rio. CRP, C reactive protein; EVALI, e-cigarette/vaping product use-associated lung injury; THC, tetrahydrocannabinol; GI, gastrointestinal; MRSA, Methicillin-resistant Staphylococcus aureus; ESR erythrocyte sedimentation rate; CXR, chest x-ray. Open in a new tab Supplemental oxygen is titrated to the patient’s clinical course. Many may require nasal cannula or non-rebreathers; however, due to the rapid nature of EVALI and progression to acute respiratory distress syndrome (ARDS), a significant percentage will require HFNC or non-invasive ventilation. Intubation and mechanical ventilation may be necessary for the most severe cases. 16 17 It is crucial to exclude other aetiologies with PCR panels, sputum and blood cultures, autoimmune workup and, if clinically appropriate, a BAL. 13 EVALI is a diagnosis of exclusion, and clinicians must meticulously exclude other causes. Another crucial aspect of treatment is psychosocial behaviour intervention. Counselling the patients to discontinue e-cigarette/vaping product use is essential to recovery and the prevention of recurrence. 1 16 As for THC users, while no exact alternatives like nicotine gum or patches exist, transitioning to oral agents such as THC-infused candies and food should be considered. Behavioural therapy has also been proven to work in curbing the desires of nicotine users and drug users and should be accessible to all patients. 18 19 Patients are typically discharged on a steroid taper regimen over 5–14 days, depending on the disease severity and response rate. 14 17 Outpatient follow-up with pulmonology is recommended for reassessment, ongoing steroid management and further testing if warranted. Some patients may experience prolonged symptoms or radiographic abnormalities post discharge, though long-term sequelae appear uncommon in most cases. 15 Patient’s perspective. The whole period is a bit blurry as I do not remember much of my stay in the hospital. Many of my friends and family who visited me tell me that I was speaking nonsense. I do remember that everything started around 3 or 4 days prior to my arrival to the hospital. I felt short of breath and my chest felt a little tight, I went to my PCP who thought I was having the flu, but I kept feeling worse so I had to go into the hospital. I was gasping for air just moving around, dizzy, my legs were weak I thought I was going to pass out at any second. I know they put me in the ICU right away with the double barrels and had me on steroids. That is when things get blurry as I was so confused, many of my family members did not know what I trying to communicate to them. After that I know I was in the oncology unit and being kept on isolation but still needing oxygen. Even after I left, I needed oxygen and it was hard to get around even with it. Sometimes I tried to take the oxygen off, just to see if I could be without it, but immediately my chest would get tight, and I would be gasping for air. The biggest feeling I had during this time was fear, anxiety, insecurity. I wasn't sure I was going to live, I had to send my children away to live with their father and even gave up my pet rabbit. Even now I still have some moments where I feel short of breath of as if I need the oxygen and it can be scary. Learning points. E-cigarette/vaping product use-associated lung injury (EVALI) remains a crucial differential diagnosis in the appropriate clinical setting in cases where infectious, autoimmune and other aetiologies have been ruled out or are inconclusive. Pathophysiology has not been fully elucidated, with multiple processes, primarily E-acetate thought to contribute to the severity of lung injury. Vaping remains an unsafe practice, and we need to do a better job of educating young people that vaping is not safer than smoking. Treatment is empiric and relies on poorly defined steroid regimens, with most patients responding within the first few days. We should make efforts to resume tracking and reporting cases alongside a focus on aiding individuals in curbing nicotine and marijuana dependency, thus reducing e-cigarette/vape usage and its potential to cause lung injury. Footnotes Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy. Provenance and peer review: Not commissioned; externally peer reviewed. Patient consent for publication: Consent obtained directly from patient(s). References 1. 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