Med Journal Nov 2020 Final 2 | Page 15

Figure 1 . Week of Symptom Onset for EVALI Patients ( N = 23 ) Reported to the Arkansas Department of Health — Arkansas , August 4 , 2019 – December 8 , 2019
individuals aged 18 – 34 years old , and 15 ( 65.2 %) were male . Injuries were reported throughout the state , although approximately half of patients resided in ADH ’ s Northwest Public Health Region ( 56.5 %). Rural Baxter County in the Northwest Region reported seven cases accounting for 30.4 % of all cases in the state .
All 23 patients required hospitalization , with a median hospital stay of six days ( range : two – 14 days ); no patient died . Twelve ( 52.2 %) patients visited a health care provider for EVALI-related symptoms before the visit for which they were ultimately admitted for hospitalization . Of these 12 patients , four first sought treatment at an urgent care center ( 33.3 %), four ( 33.3 %) at a hospital emergency department ( ED ), and four ( 33.3 %) at their primary care provider . Of 11 patients who were admitted to the hospital on the same day they first sought treatment for EVALI-related symptoms , one ( 9.1 %) presented to an urgent care provider before ED referral , and 10 ( 90.9 %) sought care directly from a hospital ED .
Clinical characteristics , diagnostic testing , and therapeutic procedures for these 23 patients are summarized in Table 2 . Influenza testing was performed for 18 ( 78.3 %) patients ; all these tests were negative . Ten patients ( 43.5 %) received a respiratory viral panel , and nine patients ( 39.1 %) had negative results for all pathogens tested . Adenovirus was detected in one patient , but the patient ’ s clinical team believed that this infection was not the sole cause of illness . Twenty-two ( 95.7 %) persons with EVALI received chest radiographs during their illness . Of these , 20 ( 90.9 %) had bilateral pulmonary infiltrates . Of 23 EVALI patients , 19 ( 82.6 %) had a chest CT scan at some point during their hospitalization , all of whom had bilateral ground-glass opacities . Eighteen ( 78.3 %) patients received both chest radiographs and one or more CT scans .
Eighteen of 23 ( 78.3 %) patients were available for interviews regarding EVP use or had complete information in their medical records on substances used in e-cigarette , or vaping , devices . Of these 18 patients , 14 ( 77.8 %) had used nicotine , 15 ( 83.3 %) had used tetrahydrocannabinol ( THC ), and two ( 11.1 %) had used cannabinoid ( CBD ) in an e-cigarette , or vaping , device in the
90 days preceding illness onset . Two ( 11.1 %) of these 18 patients reported exclusively using nicotine-containing products , three ( 16.7 %) exclusively THC-containing products , and one ( 5.6 %) CBD-containing products only . Eleven patients ( 61.1 %) used both THC and nicotine-containing products , and one ( 5.6 %) patient used nicotine , THC , and CBD-containing products .
Discussion
According to CDC , 2,807 hospitalized EVALI cases have been reported nationwide through February 2020 , and 68 deaths have been confirmed . 5 The outbreak course in Arkansas followed the national outbreak , where EVALI cases peaked in September and then steadily decreased thereafter . 6 However , despite significant progress in controlling the outbreak , some cases continue to occur . 7 Therefore , clinicians should remain vigilant for this diagnosis in patients with an EVP use history and who also have compatible respiratory , gastrointestinal , or constitutional symptoms . Clinical guidance and tools for health care providers can be found on CDC ’ s Lung Injury Outbreak webpage , including an algorithm for EVALI patient management and a discharge readiness checklist . 8
Nationwide , most EVALI patients reported use of THC-containing EVP ’ s obtained through informal sources such as family , friends , and online or in-person dealers . 8 In toxicologic anal-
Table 2 . Common Clinical Characteristics and Therapeutic Procedures of Arkansas EVALI Patients ( N = 23 )
Initial Signs and Symptomsa
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No . (%)
Shortness of breath 22 ( 95.7 ) Cough 22 ( 95.7 ) Fever or chills b 20 ( 87.0 ) Hypoxemia c 19 ( 82.6 ) Nausea or vomiting 18 ( 78.3 ) Diarrhea 9 ( 39.1 )
ICU Admission and Therapeutic Procedures ICU admission 11 ( 47.8 ) Mechanical ventilation 8 ( 34.8 ) BiPAP or CPAP 7 ( 30.4 )
Abbreviations : ICU = intensive care unit , BiPAP = bilevel positive airway pressure , CPAP = continuous positive airway pressure
a
Patients could report more than one symptom b
Subjective or objective ( temperature ≥100.4 ° F ) c
Oxygen saturation ≤95 % while breathing room air
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