Discussion
Pediatric SARS-CoV-2 infection can be complicated by a potentially life-threatening hyperinflammatory condition termed MIS-C. The severity of MIS-C, coupled with a variety of non-specific but common symptoms, such as fever and abdominal pain, as well as the broad case definition, create challenges for health care providers. Although, the presence of positive SARS-CoV-2 PCR and/or serology is helpful for diagnosis, testing may not be readily available and turnaround time can be delayed. Additionally, many children currently have potential recent exposures to COVID-19. MIS-C symptoms and clinical manifestations may overlap with those of some infectious respiratory diseases, including COVID-19, toxic shock syndrome, macrophage activation syndrome, and Kawasaki syndrome3.
MIS-C, much like EVALI, may cause severe respiratory symptoms, constitutional complaints, and similar chest imaging findings3. Our patients were admitted with fever or history of fever, severe abdominal pain, lymphopenia, significantly elevated inflammatory markers in all, and ground-glass opacities of lungs suggestive of MIS-C. D-dimers were also elevated. Differing from reported MIS-C patients was that our EVALI patients were of white ethnicity4, 5. Although our center is fortunate to have SARS-CoV-2 PCR and serology results available to us in a short period of time, these patients still had possible COVID-19 exposure; creating further challenges for treatment and management decisions. Thorough history taking helped to differentiate the illnesses and avoid unwarranted treatments in our patients. EVALI is an additional overlapping diagnosis that can be considered in older children presenting for evaluation of MIS-C, especially in the setting of negative SARS-CoV-2 testing and vaping history.
Similar to our cases, a significant number of EVALI patients reported sharing the same device or product with friends and family members, increasing their risk for COVID-19 infection 6. EVALI patients also reported vaping more to cope with pandemic associated stressors and anxiety3. These factors may partially explain the matching geographic distribution of hospitalized EVALI cases and reported COVID-19 cases currently in the US7, 8. We believe these findings have direct implications for health care providers when MIS-C is considered in older children as EVALI could present similarly. A comprehensive e-cigarette use history helped our patients have a prompt diagnosis and treatment.