EVALI and MIS-C: Overlapping Diagnoses

EVALI and MIS-C: Overlapping Diagnoses 1024 575 Mary Bates, PhD

Taking a thorough history can differentiate these similarly presenting conditions.

In a new report, researchers from Nationwide Children’s Hospital describe six patients admitted to the hospital with concerns for MIS-C who were later diagnosed with EVALI. The researchers discuss the factors that led them to differentiate between the two disorders and arrive at the correct diagnosis and treatment.

EVALI (e-cigarette or vaping use-associated lung injury) and MIS-C (multisystem inflammatory syndrome in children) are both fairly new diagnoses. Clinicians first started seeing young patients with EVALI a few years ago, and MIS-C emerged last year as a pediatric complication of SARS-CoV-2 infection. The two conditions have overlapping clinical and laboratory features, creating diagnostic challenges for health care providers.

“We know that EVALI cases can mimic an infectious process,” says Eric Mull, DO, Pediatric Pulmonary Fellow at Nationwide Children’s and one of the study’s authors. “That led us to comparing EVALI to this other new entity, MIS-C, which is associated with COVID-19 infection.”

The researchers describe six teenagers presenting with fever and severe abdominal symptoms admitted for suspected MIS-C. Laboratory and imaging findings included lymphopenia, elevated inflammatory markers, and ground-glass opacities of the lungs — all non-specific findings that could indicate MIS-C or something else.

“MIS-C and EVALI are both diagnoses of exclusion, since there is no definitive test for either of them,” says Diego Cruz Vidal, MD, Pediatric Infectious Disease Fellow at Nationwide Children’s and a co-author of the study. “You have to think about other possible explanations, before you can diagnose either MIS-C or EVALI.”

All six patients tested negative for SARS-CoV-2 infection. In addition, these patients were teenagers, while the reported median age of patients with MIS-C is around nine years old. However, the most important clue came from taking thorough histories: All patients reported a history of vaping.

“Taking a good history is vital in leading to an appropriate diagnosis,” says Dr. Cruz Vidal. “Sometimes the exposure (to E-cigarettes) happened several weeks ago, so asking those questions about things the patient might not volunteer to you is crucial.”

Dr. Mull agrees. “Given the overlapping features of MIS-C and EVALI, such as respiratory symptoms, abdominal complaints, and similar imaging findings, comprehensive investigation of vaping use helped us arrive at the proper diagnosis and treatment,” he says.

Diagnosing EVALI during the COVID-19 pandemic is a challenge for health care providers. The researchers say that astute clinicians need to keep this diagnosis in mind during examinations, especially in older children with a history of vaping.



Cruz-Vidal DA, Mull ES, Taveras J, Shell R, Hunt GW, Fowler B, Wallihan R, Erdem G. EVALI versus MIS-C, one more overlapping diagnosis to consider. Pediatric Pulmonology. 2021 Jul 5. doi: 10.1002/ppul.25558. Epub ahead of print.

Image credit: Adobe Stock

About the author

Mary a freelance science writer and blogger based in Boston. Her favorite topics include biology, psychology, neuroscience, ecology, and animal behavior. She has a BA in Biology-Psychology with a minor in English from Skidmore College in Saratoga Springs, NY, and a PhD from Brown University, where she researched bat echolocation and bullfrog chorusing.