Evali: Symptoms, Types, Causes and Treatment

E-cigarette, or vaping, product use-associated lung injury—commonly known as EVALI—emerged as a major public health concern in 2019, rapidly drawing the attention of clinicians, researchers, and the public alike. While e-cigarettes and vaping devices were once marketed as safer alternatives to traditional smoking, a wave of acute and sometimes life-threatening lung injuries changed the narrative. Understanding EVALI requires a close look at its symptoms, different injury types, underlying causes, and evidence-based approaches to treatment. This article provides a comprehensive, human-centered overview to empower readers with the latest knowledge.

Symptoms of Evali

EVALI can present with a wide range of symptoms, making early recognition a challenge. Most patients develop a constellation of respiratory, gastrointestinal, and systemic symptoms, which can be easily mistaken for other common illnesses—especially during flu season or respiratory infection outbreaks. Early identification and awareness are crucial for timely intervention.

Respiratory	Gastrointestinal	Constitutional	Source(s)
Shortness of breath, cough, chest pain, hypoxemia	Nausea, vomiting, diarrhea, abdominal pain	Fever, chills, fatigue, weight loss	1, 2, 3, 4, 5, 12

Table 1: Key Symptoms

Respiratory Symptoms

EVALI’s hallmark is respiratory distress. Most patients report:

• Shortness of breath (dyspnea): This is one of the most commonly reported and often severe symptoms, sometimes progressing rapidly to respiratory failure 1 2 3 4 5.
• Cough and chest pain: Persistent cough (sometimes dry), and chest discomfort are frequent. Some patients develop hypoxemia (low blood oxygen), requiring supplemental oxygen or even ventilation 1 2 3 5.
• Imaging findings: Chest imaging typically reveals bilateral ground-glass opacities—a hallmark of EVALI—often best seen on computed tomography (CT) scans 2 3 4 5.

Gastrointestinal Symptoms

EVALI frequently masquerades as a stomach bug:

• Nausea, vomiting, and abdominal pain: These GI symptoms are surprisingly prominent, especially in younger patients and adolescents 2 3 4. In some case series, over 80% of adolescents presented with significant GI symptoms 3.
• Diarrhea: Less common, but still reported by a notable subset 2 3 4.

Constitutional and Systemic Symptoms

These include:

• Fever and chills: Many patients initially believe they have the flu 1 4 5.
• Fatigue and malaise: Generalized tiredness is common.
• Weight loss: Some report unintended weight loss prior to diagnosis 1 7.

Diagnostic Clues

Given the overlap with other respiratory and gastrointestinal illnesses, clinicians are advised to:

• Always ask about recent use of e-cigarettes or vaping products, especially in adolescents and young adults presenting with these symptoms 5 11.
• Consider EVALI in any patient with unexplained respiratory symptoms and relevant exposure history, and obtain chest imaging when suspicion is raised 1 2 4 5 11.

Types of Evali

EVALI is not a single disease, but rather a spectrum of lung injuries triggered by vaping. The clinical presentation and imaging findings can vary, but several distinct patterns have been described. Understanding these types helps guide diagnosis and management.

Pattern	Hallmark Feature	Severity/Outcome	Source(s)
Acute lung injury (ALI)	Diffuse alveolar damage, hypoxemia	Severe, ICU common	2, 4, 5, 7
Organizing pneumonia	Patchy lung consolidation	Variable, often improves	4, 7
Lipoid pneumonia	Lipid-laden macrophages in BAL	Variable, less specific	4, 7
Hypersensitivity-like	Airway-centered inflammation	May be milder	2, 4

Table 2: EVALI Injury Types

Acute Lung Injury (ALI) and Diffuse Alveolar Damage

• Most common and severe type: Characterized by extensive, sometimes life-threatening involvement of both lungs, leading to severe hypoxemia and respiratory failure 2 4 5.
• Imaging: Bilateral ground-glass opacities, often with subpleural sparing on CT 4.
• Course: Many require ICU care; with supportive therapy, most recover if diagnosed early 1 2.

Organizing Pneumonia

• Presentation: Patchy areas of lung consolidation, sometimes mistaken for infection 4 7.
• Diagnosis: Requires exclusion of infectious causes; may respond well to corticosteroids 4.
• Course: Variable, but often less severe than acute lung injury.

Lipoid Pneumonia

• Pathology: Presence of lipid-laden macrophages in bronchoalveolar lavage (BAL) fluid 4.
• Specificity: Although initially thought to be a marker for EVALI, more recent evidence shows this finding is not specific and can occur in other scenarios 4 7.
• Clinical relevance: May guide further investigations but not diagnostic alone.

Hypersensitivity-like Reactions

• Manifestation: Airway-centered inflammation, sometimes mimicking allergic or hypersensitivity pneumonitis 2 4.
• Severity: These cases may be milder but still require close monitoring and intervention.

Pediatric and Adolescent Patterns

• Children and teens: May present with similar patterns as adults but often have more severe GI symptoms and may be more likely to require intensive respiratory support 2 3 4.

Causes of Evali

The cause of EVALI was a mystery during the early outbreak, but research has since identified key culprits—most notably vitamin E acetate. However, EVALI likely results from a combination of chemical exposures and product adulterants.

Cause/Agent	Evidence Level	Mechanism/Role	Source(s)
Vitamin E acetate	Strong	Lung toxicity, surfactant disruption	5, 6, 7, 8
THC-containing cartridges	Strong	Main exposure among patients	1, 6, 8
Other contaminants (hydrocarbons, metals, pesticides)	Moderate	Contribute to toxicity	7
Nicotine-only products	Weak	Rarely implicated	8, 9

Table 3: Major Causes and Agents

Vitamin E Acetate: The Prime Suspect

• Discovery: Analyses of bronchoalveolar lavage (BAL) fluid from EVALI patients found vitamin E acetate in nearly all cases, but not in healthy controls or in e-cigarette users without lung injury 6.
• Role: Vitamin E acetate is used as a thickening agent in illicit THC vaping products. When inhaled, it can:
  • Disrupt normal lung surfactant function
  • Cause accumulation of lipids in the lung
  • Lead to direct lung toxicity and inflammatory injury 5 6 7
• Epidemiology: The vast majority of EVALI cases reported vaping THC oils, often from illicit or counterfeit sources 1 6 8.

THC-Containing and Illicit Cartridges

• Risk profile: Use of THC-containing cartridges, especially those obtained from informal sources, is the primary risk factor 1 6 8.
• Other chemicals: Counterfeit and black-market cartridges often contain a mix of chemicals—solvent-derived hydrocarbons, silicon compounds, pesticides, and heavy metals—all of which may exacerbate lung injury 7.

Nicotine-Only E-Liquids

• Role: Early media reports focused on nicotine vaping, but subsequent investigations show that EVALI is rarely caused by nicotine-only products 8 9.
• Regulatory confusion: This misunderstanding led to some regulatory overreactions, such as flavor bans on nicotine e-cigarettes, despite little evidence implicating them in EVALI 8 9.

Other Contributing Factors

• Contaminants: Besides vitamin E acetate, other substances (e.g., plant oils, terpenes, plasticizers) have been detected in illicit cartridges, potentially compounding lung toxicity 7.
• Vulnerable groups: Adolescents and young adults, especially those experimenting with black-market THC products, are at highest risk 1 2 3 8.

Treatment of Evali

There is no single “cure” for EVALI, but timely, supportive, and multidisciplinary care can be life-saving. Treatment focuses on removing the offending exposure, managing respiratory distress, and preventing complications.

Intervention	Purpose	Outcome/Consideration	Source(s)
Vaping cessation	Eliminate exposure	Essential for recovery	1, 5, 10, 12
Supportive care	Oxygen, fluids, monitoring	Most patients improve	1, 2, 5, 10, 12
Corticosteroids	Reduce lung inflammation	Often speeds recovery, especially in severe cases	1, 2, 3, 5, 10, 12
Antibiotics	Rule out infection	Often used initially	2, 5, 11, 12
Intensive care	Severe respiratory failure	ICU, ventilation, ECMO	1, 2, 3, 4, 5
Counseling	Prevent recurrence	Substance use support	5, 10, 12

Table 4: Treatment Approaches

Vaping Cessation

• First step: Immediate cessation of all e-cigarette and vaping products is critical for halting disease progression 1 5 10 12.
• Prevention: Avoiding resumption is essential for preventing recurrence.

Supportive and Respiratory Care

• Oxygen therapy: Many patients require supplemental oxygen; some need high-flow oxygen or mechanical ventilation 1 2 5.
• Monitoring: Hospital admission is often needed for those with hypoxemia, comorbidities, or lack of reliable follow-up 5 11.
• Fluids and monitoring: Supportive care includes IV fluids, monitoring vital signs, and treating complications as they arise 2 5 12.

Corticosteroids

• Role: Systemic corticosteroids are frequently used to reduce lung inflammation and have been associated with faster clinical improvement, particularly in moderate to severe cases 1 2 3 5 10 12.
• Caution: In mild outpatient cases, steroids should be used cautiously, especially if an infectious process is still possible 11.

Antibiotics and Antivirals

• Initial use: Many patients are started on antibiotics and, during flu season, antivirals due to overlapping symptoms with pneumonia or influenza 2 5 11 12.
• De-escalation: Once infection is ruled out, unnecessary antibiotics should be discontinued.

Advanced Care: ICU and ECMO

• Severe cases: Patients with respiratory failure may need intensive care, including mechanical ventilation or extracorporeal membrane oxygenation (ECMO) in rare, life-threatening cases 1 2 3 4 5.

Counseling and Prevention

• Substance use counseling: Education and support for vaping cessation and avoidance of illicit products are critical, especially for adolescents 5 10 12.
• Reporting: EVALI cases should be reported to public health authorities for surveillance and outbreak response 5.

Conclusion

EVALI represents a complex and evolving public health challenge, but improved understanding of its symptoms, injury types, causes, and evidence-based treatments can save lives. Key takeaways include:

• Symptoms: EVALI presents with a mix of respiratory, gastrointestinal, and constitutional symptoms; shortness of breath and GI complaints are especially common in adolescents.
• Types: EVALI encompasses several lung injury patterns, with acute lung injury and organizing pneumonia being the most common.
• Causes: Vitamin E acetate, especially in illicit THC vaping products, is the primary culprit; nicotine-only products are rarely implicated.
• Treatment: Early cessation of vaping, supportive respiratory care, cautious use of corticosteroids, and prevention counseling are the mainstays of treatment.

Staying informed and vigilant, especially among youth populations, is essential to prevent and manage this potentially life-threatening condition.