A 27-year-old Hispanic female college student with no significant past medical history presented to the emergency room with fever, chills, productive cough with dark phlegm, rhinorrhea, headaches along with abdominal pain, and shortness of breath for 2 days. Vital signs revealed fever of 103 °F, heart rate (HR) of 75 beats per minute, respiratory rate (RR) of 16 breaths per minute, blood pressure (BP) 128/77 mm Hg, and saturating 94% on room air. Physical examination was unremarkable except for diminished breath sounds with rales bilaterally. Chest X-ray (CXR) revealed right lung base infiltrate. The patient was diagnosed with community-acquired pneumonia and was discharged on oral azithromycin, ondansetron, and ibuprofen.

She returned to the emergency room the following day with progressively worsening shortness of breath. Her RR was 24 breaths per minute and saturating 84% on room air. Computed tomography angiogram (CTA) of the chest with and without contrast revealed bilateral patchy ground glass opacities within the bronchovascular distribution (Figure 1). The patient’s clinical condition deteriorated over the next 12 hours requiring high-flow oxygen and repeat imaging showed worsening bilateral pulmonary opacities. On further questioning, the patient admits to smoking marijuana, which she switched to vaping with CBD/THC oil 2 months prior to this presentation, which she bought off the street. She never smoked cigarettes. She denied having any pets, recent travel history, or exposure to any sick contacts. Laboratory workup was significant for leukocytosis, elevated erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), procalcitonin, and urine drug screen was positive for cannabinoids/THC (Table 1). Airway examination was normal on bronchoscopy and bronchoalveolar lavage (BAL) gram stain showed mixed respiratory flora and cultures were negative bacterial, fungal, and viral pathogens. BAL differential showed 5% neutrophils, 10% lymphocytes, and 85% macrophages. Antibiotics were escalated to ceftriaxone and azithromycin for 5 days. She also received methylprednisone 60 mg daily × 3 days, then changed to oral prednisone 40 mg daily with a tapering course of 10 mg per week over a 4-week period. A presumptive diagnosis of VALI secondary to vaping CBD/THC was made as the patient responded very well to the steroids. Her symptoms significantly improved and was discharged home 7 days later without the need for supplemental oxygen.

Case No.	Age in years	GI symptoms	Fever	Urine drug screenb	ESR	CRP	WBC	Procalcitonin level (reference ≤0.5 ng/mL)	Number of days patients was on steroids during hospitalization	Length of stay
1	27	No	Yes	Cannabinoid/THC	83	27	22 000	2.05	7 days	7 days
2	20	Yes	yes	Cannabinoid/THC	86	37.5	17 200	2.19	5 days	6 days
3	38	No	yes	Cannabinoid/THC	111	NA	8000	1.83	5 days	7 days
4	19	No	yes	Cannabinoid/THC	114	38.3	16 800	0.17	4 days	10 days
5	34	Yes	yes	Cannabinoid/THC and benzodiazepines	107	35	12 100	86.64	10 days	12 days
6	27	No	yes	Cannabinoid/THC	NA	NA	15 000	NA	5 days	8 days
7	27	No	yes	NA	90	NA	16 900	0.46	16 days	16 days

A 20-year-old Caucasian male college student with medical history of depression and anxiety presented with subjective fevers, shortness of breath, productive cough, nausea, vomiting, and epigastric pain for 4 days. Patient admits experiencing similar symptoms 2 months prior to this presentation and was treated with oral antibiotics for 10 days as an outpatient. He denied smoking cigarettes but admits vaping cannabinoid (CBD/THC mix) oil. Denies having any pets, recent travel, or exposure to sick contacts. Vital signs on presentation were temperature of 103 °F, HR 111 beats per minute, BP 130/83 mm Hg, RR 40 breaths per minute, and saturating 91% on room air. Physical examination was significant for respiratory distress and decreased breath sounds on both lung bases. Laboratory workup was significant for leukocytosis, elevated ESR, CRP, procalcitonin, and urine drug screen was positive for cannabinoids/THC (Table 1). Urine drug screen was positive for cannabinoids/THC. Extensive infectious workup including sputum studies, urine, and serum studies were negative (Table 1). CXR showed bilateral air space disease and CT of the chest without contrast showed bilateral upper lobe ground glass opacities and lower lobe dense consolidations (Figure 2). Ultrasound of the abdomen was unremarkable. Supportive care was provided by oxygen supplementation via high-flow nasal cannula to maintain saturations above 90%. He was initiated on methylprednisolone 60 mg intravenously (IV) twice a day for presumed VALI. He was discharged home with 2 L of supplemental oxygen via nasal cannula on prednisone 40 mg daily with a 3-week steroid taper regimen.

A 38-year-old old Hispanic male with medical history of anxiety presented to the emergency room complaining of fever, shortness of breath, productive cough with green phlegm, and body aches for 2-day duration. He denies any sick contacts or recent travel. He admits to vaping CBD/THC, most recently purchased from a local Los Angeles county dispensary. Vitals signs on presentation were temperature 102.5 °F, HR 113 beats per minute, BP 132/82 mm Hg, RR 24 breathes per minute, and oxygen saturation of 87% on room air. Physical examination was remarkable for respiratory distress and bilateral coarse breath sounds on auscultation. Laboratory workup was significant for elevated ESR, procalcitonin, and urine drug screen was positive for cannabinoids/THC (Table 1). Initial CXR showed bilateral infiltrates and CT chest without contrast showed bilateral patchy glass patchy opacities with subpleural sparing and small right pleural effusion (Figure 3). Extensive infectious workup including sputum studies, urine, and serum studies were negative (Table 1). The patient was subsequently diagnosed with respiratory failure secondary to VALI from CBD/THC vaping. He was started on IV methylprednisone 60 mg daily for 2 days and then converted to oral prednisone 40 mg daily. He clinically improved and was discharged on room air with steroid taper to be completed in 2 weeks.

A 19-year-old Hispanic female with no significant past medical history presented with fever, chills, shortness of breath, and productive cough with whitish phlegm for 4 days. Her social history was significant for vaping-flavored nicotine and vaping CBD/THC oil 1 week prior to developing current symptoms. She also admits decreased appetite with a 15-pound weight loss since the last month. Denies any recent travel history or exposure to sick contacts. Vital signs on presentation were temperature of 100.7 °F, HR 137 beats per minute, BP 105/60 mm Hg, RR 18 breaths per minute, and oxygen saturation of 98% on 2 L nasal cannula. Lungs were clear to auscultation and the rest of the physical examination was also unremarkable. Laboratory workup was significant for leukocytosis, elevated ESR, CRP, and urine drug screen positive for cannabinoids/THC (Table 1). Initial CXR showed left basilar infiltrate and she was started on levofloxacin for presumed pneumonia. Her respiratory status declined over the next few days and CTA of chest later showed bilateral upper lobe ground glass opacities (Figure 4). Airway examination was normal on bronchoscopy and BAL gram stain showed mixed respiratory flora and cultures were negative for bacterial, fungal, and viral pathogens. BAL differential showed 60% neutrophils, 30% lymphocytes, and 10% macrophages. Given negative infectious workup, no other etiology identified for respiratory failure and imaging consistent with VALI from CBD/THC vaping, she was initiated on 60 mg of IV methyl prednisone daily and switched to 40 mg of oral prednisone 2 days later. Her symptoms subsequently resolved, and she was sent home on room air with a tapering steroid course over 2 weeks.

A 34-year-old Caucasian female waitress at a local restaurant presented with complaints of worsening dyspnea, productive cough with yellow phlegm, nausea, vomiting, generalized weakness, and diarrhea for 2 weeks duration. She was prescribed azithromycin 10 days prior to this presentation without any improvement in her symptoms. She denied any sick contacts or travel abroad. She is a current cigarette smoker and also started vaping CBD/THC oil a year ago. She admits vaping CBD/THC oil bought from a local dispensary 2 days prior to her symptom initiation. On physical examination, the patient was in respiratory distress with vital signs of temperature 100.8 °F, HR 136 beats per minute, BP 123/88 mm Hg, RR 22 breaths per minute, and oxygen saturation of 88% on room air. Physical examination was significant for decreased breath sounds throughout the lung fields. Laboratory workup was significant for leukocytosis, elevated ESR, CRP, and urine drug screen was positive for cannabinoids/THC (Table 1). Extensive infectious workup including sputum studies urine and serum studies were negative (Table 1). CXR showed bilateral interstitial infiltrates and CTA of the chest with and without contrast confirmed bilateral upper lobe ground glass patchy infiltrates (Figure 5(a)). She was diagnosed with acute hypoxic respiratory failure likely from VALI secondary to vaping CBD/THC oil. The patient was started on IV methylprednisolone 60 mg daily and then transitioned to oral prednisone 40 mg daily. A repeat CT chest with contrast 6 days after steroid initiation showed interval improvement of patchy bilateral infiltrates with a small residual superior segment of right lower lobe ground glass opacity (Figure 5(b)). She was discharged home with a tapering course of steroids for a total to 2 weeks.

A 27-year-old Hispanic female with no significant past medical history presented with progressively worsening dyspnea, nonproductive cough, subjective fevers, nausea, decreased appetite, and fatigue for 10 days. The patient was also vaping CBD/THC oil intermittently. She was alert and oriented on physical examination and in mild respiratory distress, noted to have diffuse bilateral wheezing with rhonchi on auscultation. Vital signs showed temperature 102 °F, HR 122 beats per minute, BP 131/72 mm Hg, RR 24 breaths per minute, and oxygen saturation of 96% on 2 L nasal cannula. Laboratory workup was significant for leukocytosis, elevated ESR, CRP, and urine drug screen was positive for cannabinoids/THC (Table 1). Extensive infectious workup including sputum studies urine and serum studies were negative (Table 1). CTA of the chest showed bilateral diffuse ground glass opacities with septal thickening, tree in bud opacities, and bilateral pleural effusions (Figure 6). She was diagnosed with community-acquired pneumonia and was started on azithromycin and ceftriaxone. As the hypoxia did not improve with antibiotics, she was later started on IV methylprednisolone 60 mg daily for 3 days, changed to oral prednisone 40 mg daily for presumed VALI. Extensive infectious workup including sputum studies urine and serum studies were negative (Table 1). She received azithromycin and ceftriaxone for a total of 5 days during her hospital stay. Repeat CXR showed an improvement, and the patient was discharged home with a steroid taper for a total of 2 weeks.

A 27-year-old Hispanic male presented to the urgent care with complaints of fatigue and generalized body aches for 2 weeks with fever 101.5 °F. CXR at that time showed basilar interstitial infiltrates and was sent home with doxycycline for presumed pneumonia. Subsequent follow-up with primary care provider 3 days later showed worsening dyspnea and a new left side pleuritic chest pain. The patient was advised to complete his prescribed antibiotic course and also given a prescription for albuterol, fluticasone-salmeterol inhalers. The following day, the patient presented to the emergency room with worsening respiratory symptoms and is concerned that he is having vaping lung injury after seeing a local news report about the possible lung problems associated with vaping. The patient admitted vaping THC daily. He complained of worsening shortness of breath on exertion along with decreased appetite. He denied any nausea and vomiting. On physical examination, the patient was in respiratory distress with temperature of 99.2 °F, HR 128 beats per minute, BP 135/79 mm Hg, RR 31 breaths per minute, and oxygen saturation of 89% on 4 L of nasal cannula. Auscultation of the lungs revealed diminished coarse breath sounds throughout the lung fields. Pertinent abnormal laboratory workup was mentioned in Table 1. CXR showed bilateral patchy opacities and CTA of the chest showed diffuse ground-glass opacities with crazy paving pattern with subpleural sparing (Figure 7). Extensive infectious and autoimmune workup was negative. The patient was diagnosed with VALI secondary to vaping THC. He was started on high dose of methylprednisone 60 mg IV every 12 hours for 2 days then transitioned to oral prednisone. He decompensated after switching to oral steroids, hence IV methylprednisone 60 mg IV q12 hours was restarted for 5 more days, then again tapered to oral steroids. His oxygen saturation was maintained with high-flow nasal cannula at 70% and 50 L. He was discharged home on 2 L of oxygen via nasal cannula along with steroid taper over the next 3 weeks.