Have pleural effusions been reported in association with vaping or electronic (e-) cigarette use?

Pleural Effusions in Vaping-Associated Lung Injury

Yes, pleural effusions have been documented as a clinical manifestation of e-cigarette or vaping product use-associated lung injury (EVALI). Multiple studies have confirmed the presence of pleural effusions in patients with vaping-related lung injury, with approximately 50% of EVALI patients demonstrating this finding on imaging.

Epidemiology and Clinical Evidence

Pleural effusions represent a significant radiographic finding in EVALI cases:

• In a study of adolescents with EVALI, 50% demonstrated small pleural effusions on chest CT imaging 1
• Case reports have documented rapidly evolving pleural effusions requiring thoracotomy in previously healthy individuals with a history of heavy e-cigarette use 2
• Bilateral pleural effusions have been observed alongside other characteristic EVALI findings such as ground-glass opacities and interlobular septal thickening 3, 4

Radiographic Findings in EVALI

The typical imaging pattern of EVALI includes:

• Centrilobular ground-glass nodules (92% of patients)
• Confluent ground-glass opacities (100% of patients)
• Subpleural sparing (75% of patients)
• Pleural effusions (50% of patients)
• Hilar or mediastinal lymphadenopathy (75% of patients)
• Bronchial wall thickening (50% of patients) 1

Clinical Presentations Associated with Pleural Effusions in EVALI

Patients with EVALI who develop pleural effusions may present with:

• Pleuritic chest pain
• Progressive dyspnea
• Cough
• Systemic symptoms (fever, fatigue)
• Respiratory failure in severe cases 2, 5

Pathophysiological Mechanisms

The development of pleural effusions in EVALI appears to be related to:

• Direct toxic injury to the lung parenchyma from vaping chemicals
• Inflammatory response to inhaled substances
• Potential hypersensitivity reactions to vaping components 5, 3

Diagnostic Approach for Suspected EVALI with Pleural Effusion

According to CDC guidance, the diagnostic workup should include:

1. Detailed history of e-cigarette or vaping product use
2. Chest imaging (radiograph and CT)
3. Exclusion of infectious etiologies
4. Consideration of bronchoalveolar lavage showing:
   • Inflammatory cells
   • Lipid-laden macrophages
   • Possible eosinophilia 6

Management Considerations

The CDC recommends the following approach for EVALI patients:

• Complete cessation of all e-cigarette and vaping product use
• Hospitalization for patients with significant respiratory compromise
• Consideration of corticosteroid therapy
• Close monitoring for clinical deterioration
• Follow-up within 48 hours of discharge for hospitalized patients 6

Important Caveats and Pitfalls

1. Misdiagnosis risk: EVALI shares clinical and radiographic features with infectious pneumonia, hypersensitivity pneumonitis, and other acute lung injuries. Always obtain a thorough vaping history.

2. Delayed recognition: Patients may not disclose vaping habits unless specifically asked, particularly adolescents.

3. Rapid progression: Cases have been documented where pleural effusions evolved rapidly, requiring urgent intervention 2.

4. Differential diagnosis: Unlike pulmonary Langerhans cell histiocytosis (which is associated with traditional cigarette smoking), EVALI commonly presents with pleural effusions and does not typically demonstrate the cystic changes characteristic of PLCH 6, 7.

In summary, pleural effusions represent a well-documented manifestation of vaping-associated lung injury, occurring in approximately half of EVALI cases. Clinicians should maintain a high index of suspicion for EVALI in patients with unexplained pleural effusions, particularly when accompanied by a history of e-cigarette or vaping product use.