Table 1 Timeline

Patient is a 27-year-old African American male.

Patient has a 2-year history of cigarette tobacco use and vaping of tetrahydrocannabinol (THC).

Patient presents to an emergency room with a 2-week history of nonproductive cough, subjective fever, rhinorrhea, chills, myalgia, diarrhea, and vomiting. He is diagnosed with a viral upper respiratory tract infection and is discharged.

Two days later, in mid-December 2019, because of worsening symptoms, patient is admitted to an outside hospital.

Infection work up is positive for Influenza-A by nasal swab, and sputum grows methicillin-sensitive Staphylococcus aureus (MSSA) a few days later.

Initial chest x-ray reveals patchy infiltrates of the right upper and bilateral lower lobes that are consistent with multifocal pneumonia (Fig. 1).

Patient’s respiratory status declines rapidly, and he is transferred to the intensive care unit (ICU) and intubated for respiratory failure.

Bronchoscopy shows evidence of damage to the trachea and upper bronchi, likely due to vaping.

Treatment is started with vitamin C, thiamine, hydrocortisone and multiple antibiotics (vancomycin, cefepime, azithromycin and doxycycline) for concern of sepsis as well as oseltamivir for Influenza A.

Patient’s clinical condition continues to deteriorate, and he is transferred for a higher level of care.

Patient is treated with V-V ECMO, VA-ECMO and IABP.

Patient develops acute renal failure, liver failure, biventricular systolic dysfunction and rhabdomyolysis.

Patient expires after a total hospital course of 2 weeks.

Autopsy is performed and reveals severe DAD and lipid-laden macrophages consistent with lipoid pneumonia.