A previously healthy 17-year-old came to the emergency department with nausea, vomiting, diarrhea, shortness of breath, and chest pain. He had begun experiencing gastrointestinal symptoms five days earlier following a family picnic. When asked, he said that one of his friends was diagnosed with “walking pneumonia” and another one tested positive for COVID-19.

In the ED, the patient looked very ill; he was pale, feverish, coughing, and breathing rapidly. Lab tests showed that his white blood cell count was very high, which can often signal infection, and he had an abnormal chest X-ray. Over the next three hours, his condition worsened, and he was struggling to breathe. He was started on oxygen through his nose, but his breathing deteriorated, and he was transferred to the pediatric intensive care unit (PICU).

The patient’s initial symptoms — nausea, vomiting, and diarrhea — suggested food poisoning. Food-borne illness occurs when food is not washed thoroughly, handled in a sanitary way, cooked to a safe internal temperature, or refrigerated or frozen promptly. This could have happened at the family picnic, but chest pain and shortness of breath are not usually symptoms of food poisoning.

This patient had been exposed to someone who had COVID-19 and although his symptoms were consistent with the disease, he tested negative.

In the PICU, he was in respiratory failure and was put on a ventilator. However, even on the ventilator, his vital organs couldn’t get enough oxygen. To save his life, the decision was made to start him on extracorporeal membrane oxygenation (ECMO), a machine that acts as an “artificial heart and lung.”

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His care team also considered “walking pneumonia,” a term used to describe a mild form of pneumonia, in which patients may feel as if they have a cold. However, his level of respiratory distress requiring ECMO was much too severe to be consistent with walking pneumonia.

After 14 days, the patient’s oxygen level improved enough for him to be weaned off ECMO and put back on the ventilator.

He had multiple other complications in the PICU, including high blood pressure, a pressure wound, bleeding in his brain, and air leaks into his chest wall. Ultimately, he was in the PICU for 87 days.

What caused this young man to become so sick?


Upon further questioning, our patient disclosed that he had been vaping both nicotine (with a JUUL device) and marijuana (through a vaporizer pen) for more than two years. That information sparked another likely diagnosis: E-cigarette or vaping use-associated lung injury, also known as EVALI.

EVALI is a severe lung illness, first identified in 2019, that results from E-cigarette chemicals irritating and damaging the lungs and ultimately causing severe lung damage or even death.

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Although it is primarily a lung disease, EVALI can present with diarrhea, vomiting, and fever. The patient’s history, abnormal chest X-ray results, and severity of illness were consistent with EVALI.

The only way to prevent EVALI is to stop vaping. Because the illness is still new, there is much we don’t know about its long-term consequences.

According to the CDC, e-cigarettes are currently the most commonly used tobacco product among youth. In 2020, one out of five high school students reported that they had used e-cigarettes in the last 30 days.

Our advice: It’s time to talk with your teenagers about vaping. Chances are, even if they are not vaping, they know someone who is. And chances are, they do not know about EVALI.

Rima Himelstein is an adolescent-medicine specialist and Hayley Goldner is a third-year pediatric resident at Nemours Children’s Hospital, Delaware.