TOPIC: Lung Pathology TYPE: Medical Student/Resident Case Reports INTRODUCTION: During these unprecedented times of COVID it is important to not lose sight of other epidemics that impact public health. The e-cigarette/vaping epidemic is one example with a rise in the associated lung injury. This case report aims to highlight two cases of EVALI and highlight their clinic course. CASE PRESENTATION: Case Report #1: A 55 y/o male with a medical history of squamous cell carcinoma with right pneumonectomy, COPD & CAD presented with complaints of shortness of breath. He had been hospitalized 4 times with 2 intubations in a 3-month period, each time when steroids were tapered;further history revealed he had vaped since he quit smoking 5 years ago. He was noted to have a leukocytosis and diffuse interstitial infiltrates on radiography. CT angiography was negative for pulmonary embolus. Antibiotics were started, but infectious workup was unrevealing. High dose steroids were started. He eventually required intubation. Pneumonitis was therefore considered. He was evaluated for lung biopsy and transplant, but was not deemed a suitable candidate. His clinical status continued to decline, and family opted for a compassionate extubation and inpatient hospice.Case Report #2: A 43 y/o male with PMH of polysubstance abuse and schizoaffective disorder was admitted for acute hypoxic respiratory failure. He reported vaping for the last 3 years, former smoker prior to this. CT angiogram at the time showed findings consistent with ARDS. He eventually was intubated. Initial concern for pneumonia and blood culture did grow klebsiella, however bilateral infiltrates persisted despite adequate antibiotics. Rheumatological workup was unrevealing. Eventual open lung biopsy was performed and samples showed diffuse alveolar damage. He was started on high dose steroids and eventually extubated and discharged. He did continue to vape and had similar admission presentation several days later. DISCUSSION: EVALI serves as a diagnosis of exclusion, linked to vitamin E in vaping. There is a spectrum of acute lung injury in this pathology, which both of these cases highlight. The first shows this disease in a single lung patient, a unique presentation, while the second showcases a more classic form. Thorough explanation of all etiologies of interstitial lung disorders is necessary. Both of these cases help to provide further information and data on the growing body of knowledge. CONCLUSIONS: Originally vaping was thought as an option in smoking cessation. However, these cases indicate the complications associated with the practice of vaping (i.e. development of pneumonitis and respiratory failure). It is imperative to determine the drivers of vaping practices and focus on awareness campaigns to reduce its use. Furthermore, research should be directed towards specific clinical and radiological manifestations for early detection and attempt to reverse pulmonary damage. REFERENCE #1: Jonas AM, Raj R. Vaping-Related Acute Parenchymal Lung Injury: A Systematic Review. Chest. 2020 Oct;158(4):1555-1565. doi: 10.1016/j.chest.2020.03.085. Epub 2020 May 19. PMID: 32442559. REFERENCE #2: Belok SH, Parikh R, Bernardo J, Kathuria H. E-cigarette, or vaping, product use-associated lung injury: a review. Pneumonia (Nathan). 2020 Oct 25;12:12. doi: 10.1186/s41479-020-00075-2. PMID: 33110741;PMCID: PMC7585559. REFERENCE #3: Feldman R, Stanton M, Suelzer EM. Compiling Evidence for EVALI: A Scoping Review of In Vivo Pulmonary Effects After Inhaling Vitamin E or Vitamin E Acetate. J Med Toxicol. 2021 Feb 2. doi: 10.1007/s13181-021-00823-w. Epub ahead of print. PMID: 33528766. DISCLOSURES: No relevant relationships by Nayab Ahmed, source=Web Response No relevant relationships by N Hasan Choudhury, source=Web Response No relevant relationships by Wesley Field, source=Web Response No relevant relationships by Dhaval Patel, source=Web Response