TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Vaping and e-cigarettes are devices with aerosolized substances such as nicotine, tetrahydrocannabinol (THC), or cannabinoids (CBD) along with a carrying media. Their introduction in the past two decades has coincided with the advent of devastating lung injuries.3 Cannabinoid hyperemesis syndrome is a paradoxical condition where chronic cannabinoid use causes cyclic episodes of nausea or vomiting. Vaping injury to the lungs combined with cyclical emesis episodes has the potential to cause severe damage as shown in our case. CASE PRESENTATION: A 32 year-old male with a six-month chronic cough, daily marijuana and vape use presented with a headache, abdominal discomfort, nausea and loose stools after one week of acutely worsened cough and emesis. On the second day of admission he developed a leukocytosis, acute renal failure, an elevated lactate and transaminitis. Abdominal Computed Tomography(CT) scan showed hepatic steatosis with normal lung bases. Rapid encephalopathy and shock necessitated endotracheal intubation and vasopressor support. He transferred to our tertiary care center for emergent hemodialysis while on four vasopressor medications, stress dose steroids, minimal ventilator settings and no sedation. Initial minimal ventilator support worsened to severe acute respiratory distress syndrome (ARDS) by 48 hours with a calculated PaO2/FiO2 ratio of 97 on 15 positive end-expiratory pressure. Broad spectrum coverage was narrowed to empiric pneumonic coverage after an unrevealing infectious lumbar puncture. Figure 1 shows the diffuse airspace disease with air bronchograms and dense bibasilar consolidations four days into admission in the coronal and axial view. He slowly weaned from high ventilator settings and was successfully extubated on day fourteen. DISCUSSION: Our case shows the rapid development of pulmonary decompensation and evolution of multisystem failure in a patient with aspiration pneumonia secondary to cannabinoid vaping use. Imaging of electronic vaping associated lung injury often shows basilar-predominant consolidation and ground-glass opacity with areas of lobular or subpleural sparing. 1,2 His clinical presentation and imaging was suggestive of the novel VARDS classification. With his minimal response to steroids and routine supportive care, we propose the patient's chronic vaping history predisposed our patient to a prolonged and unusually severe presentation. CONCLUSIONS: More research is needed regarding the relation between vaping associated lung injury and its progression to ARDS and multisystem organ failure. REFERENCE #1: Aberegg SK, Maddock SD, Blagev DP, Callahan SJ. Diagnosis of EVALI: General Approach and the Role of Bronchoscopy. Chest. 2020;158(2):820-827. doi:10.1016/j.chest.2020.02.018 REFERENCE #2: Henry TS, Kanne JP, Kligerman SJ. Imaging of vaping-associated lung disease. N Engl J Med. 2019;381(15):1486-1487. doi:10.1056/NEJMc1911995 REFERENCE #3: Kalininskiy A, Bach CT, Nacca NE, et al. E-cigarette, or vaping, product use associated lung injury (EVALI): case series and diagnostic approach. Lancet Respir Med. 2019;7(12):1017-1026. doi:10.1016/S2213-2600(19)30415-1 DISCLOSURES: No relevant relationships by Catherine Fiore, source=Web Response No relevant relationships by Kyle Halligan, source=Web Response No relevant relationships by Siddhartha Narayanan, source=Web Response