E-pipe and the lung: clinical and radiologic insights into vaping-related lipoid pneumonia

Abstract Lipoid pneumonia (LP) is an uncommon pulmonary condition marked by the presence of lipids within the alveoli and lung interstitium, potentially leading to significant respiratory impairment, often due to the inhalation or aspiration of lipid substances. Lipid-based substances can be conveyed endogenously or exogenously, and we can observe acute or chronic forms with episodic exacerbation. The true incidence is unknown, and the reasons are probably related to uncertain and missing anamnesis, discordance between clinical, radiological, and pathological imaging, geographic areas, and lack of awareness of the possible harm related to the use of some substances mistakenly considered inert or poorly toxic. The growing popularity of electronic cigarettes (e-cigarettes) has been linked to a new form of LP, which is now recognized as one of the lung injuries associated with vaping, collectively known as EVALI (e-cigarette or vaping-associated lung injury). The earliest large cluster of EVALI cases emerged in the USA in 2019, with the majority occurring in adolescents and young adults (Layden et al. in N Engl J Med 382(10):903–916, 2020). Here, we describe the case of a 62-year-old man who developed LP after approximately two years of habitually using an e-pipe. Presenting with persistent cough, occasional periods of fever, and dyspnea in March 2024, the patient’s condition remained unresponsive to antibiotic therapy. Imaging studies (chest X-ray, computed tomography (CT), and positron emission tomography-computed tomography (PET-CT), revealed lobulated coarse consolidations in the right middle lobe and left lower lobes with hypodense areas showing negative attenuation values, highly suggestive of lipid components. Bronchoscopy with bronchoalveolar lavage (BAL) later revealed numerous lipid-laden foamy macrophages. This finding, combined with the patient's medical history, confirmed the diagnosis of vaping-induced lipoid pneumonia. This case highlights the diagnostic challenges posed by the diverse clinical and radiological manifestations of EVALI, and it emphasizes the importance of recognizing e-cigarette use as a potential cause of pulmonary disease.