Vape pens and unregulated THC oils are a concerning healthcare issue as multiple cases of acute pulmonary injury linked to their use have been reported across the US. We present a case of acute hypoxic respiratory failure and hypersensitivity pneumonitis secondary to vaping. CASE PRESENTATION: 32 y/o M with a history of opioid dependence and depression presented to the ED with generalized malaise, nausea, and vomiting for 3 days. Initially, his symptoms were concerning for opioid withdrawal due to his claim that his Suboxone compliance was limited due to his presenting symptoms. Pertinent vital signs were within normal limits including oxygen saturation of 97% on ambulation. His chest radiograph revealed reticular opacities in bilateral mid-lower lung fields, associated with WBC of 21.20 K/L. Following a CT chest scan was performed and showed bilateral lower lobe predominant patchy ground-glass and centrilobular opacities concerning for hypersensitivity pneumonitis (HP) or aspiration pneumonitis. Upon our evaluation, further questioning revealed a 3-year vaping history of a popular nicotine substance. Of note, 3 days prior to presentation he substituted the nicotine cartridge to a THC-laden vape cartridge. Despite the radiographic findings, he noted a clinical improvement in the ED and was released on inhaled and oral corticosteroids and advised cessation of all inhalation insults. The following day he returned to the ED with acute onset of shortness of breath and hypoxia of 70%. ABG showed Po2 60, SaO2 92.3% on FiO2 60%, with a P/F ratio of 100, indicating moderate ARDS as a result of vaping induced hypersensitive pneumonitis. The treatment course consisted of Hi-Flow oxygen, systemic steroids, and supportive care. As a result, he was transitioned to a nasal cannula and a weaning dose of systemic steroids upon discharge home. DISCUSSION: Hypersensitivity Pneumonitis (HP) is a type of interstitial lung disease caused by repeated exposure and sensitization to antigens leading to parenchymal inflammation. In vaping common antigens are formaldehyde from Propylene Glycol and terpene and benzene from Butane Hash Oil. Three forms of HP include: acute, subacute and chronic. Diagnosis is based on a history of exposure, nonspecific clinical symptoms of malaise, fever, dyspnea, and cough associated with patchy or diffuse bilateral ground-glass opacities and poorly defined centrilobular nodules on imaging. The treatment consists of avoidance of the causative antigen and high dose corticosteroids. In patients with chronic HP unresponsive to treatment a lung transplant can be considered. CONCLUSIONS: This patient's abrupt transition to THC cartridges led to his acute disease process. This case stresses the importance of history taking for the diagnosis of HP. It also emphasizes Vape pens and unregulated THC oils require both careful study and attention from regulatory organisms and health professionals.

INTRODUCTION: Cardiorespiratory disorders usually present with acute respiratory distress; likewise, ureteral rupture usually presents as an acute abdomen [1]. We report a case of ureteral rupture presenting with acute respiratory distress leading to a delayed diagnosis.CASE PRESENTATION: An 82 y/o M with a history of congestive heart failure (CHF), chronic obstructive pulmonary disease, chronic renal failure and recently diagnosed COVID -19 pneumonia, was admitted for progressive dyspnea and abdominal discomfort for 2 days. Arterial blood gas showed hypercapnic hypoxic respiratory failure. Chest computed tomographic (CT) scan without contrast showed moderate right-sided pleural effusion but pulmonary embolism (PE) could not be ruled out. He also had a left leg deep venous thrombosis with worsening renal function and B-type natriuretic peptide (BNP) of 139pg/ml.His symptoms were thought to be due to acute decompensated CHF, COVID-19 pneumonia and possible PE. He failed to improve with intravenous furosemide, bilevel positive airway pressure ventilation and empiric anticoagulation. Due to worsening renal function and abdominal pain, an abdominal CT was done which showed right ureteral rupture with retroperitoneal collection and multiple non-obstructing renal calculi. The patient had placement of a double J stent with prompt resolution of respiratory distress.DISCUSSION: There are very few case reports of ureteral rupture occurring spontaneously and causing marked dyspnea. Respiratory distress may occur if the extravasated urine leads to an urinothorax or abdominal compartment syndrome [1]. Suspicion of non-cardiorespiratory causes of acute dyspnea in patients with underlying congestive heart failure includes respiratory distress disproportionate to the size of pleural effusion, unilateral effusions or effusions of markedly disparate size, absence of pulmonary vascular congestion and cardiomegaly, worsening renal function, ascites, urinary retention or anuria, abdominal pain, failure of the effusion to respond to management of heart failure, fever or pleuritic chest pain, and low or nearnormal natriuretic peptides [2,3].When there are concerns for non-cardiorespiratory causes of respiratory distress, the diagnosis can be made with thoracentesis and imaging such as abdominal ultrasound, or CT [2].CONCLUSIONS: This case illustrates a rare presentation of ureteral rupture causing respiratory distress and the key points that should elicit high clinical suspicion for non-cardiorespiratory causes of acute respiratory distress. When these findings are present, appropriate investigations and urgent intervention may be life-saving.

INTRODUCTION: Severe Gestational Hypertriglyceridemia (HTG) is a rare but potentially life-threatening condition, which can lead to devastating complications, including acute pancreatitis (AP), hyperviscosity syndrome, preeclampsia, maternal & fetal morbidity & mortality. CASE PRESENTATION:A 33-year-old female G3P1þ1 at 37-week gestation, presented with acute abdominal pain nausea & vomiting. She admitted consuming a high fat high carb diet for a few weeks before presentation. Family history significant for her mother was diagnosed with familial Chylomirconemia & AP in pregnancy due to HTG. On presentation her vital signs were stable, physical exam consistent with early labor & negative for eruptive xanthomas. Labs showed Lipase 1,106 U/L, Amylase 750 U/L, TG 5,531 mg/dl, Cholesterol 702 mg/dl, ALP 163 U/L & glucose 82 mg/dl. She underwent C-section after which she was admitted to ICU for treatment of AP with aggressive fluid resuscitation, insulin drip with dextrose infusion & Gemfibrozil. Abdominal US revealed no biliary stones with CT abdomen revealing edematous pancreas & a region of hypoattenuation suspicious for necrotizing pancreatitis & was started on IV antibiotics. Insulin Drip was stopped once TG were less than 700 mg/ dl & symptoms resolved. She was discharged on Gemfibrozil & fish Oil.DISCUSSION: Plasma TG level normally increases 2-4 folds in pregnancy secondary to hormonally driven changes in the liver & adipose tissue with the most profound increase in the 3rd trimester as high estrogen enhances hepatic TG synthesis. Concomitantly, insulin resistance caused by human placental lactogen decreases lipoprotein lipase activity which increases adipose tissue lipolysis & free fatty acids needed for TG synthesis(1). Gestational HTG is defined as fasting plasma TG level above the age-adjusted 95th percentile for the non-pregnant population. Severe HTG defined as TG levels greater than 1000 mg/dl as it's associated with an increased risk of AP which represents a diagnostic challenge in pregnancy due to nonspecific presentation & imaging limitation(1,2). Severe Gestational HTG is typically seen in patients with underlying genetic abnormalities in TG metabolism which most likely what our patient has given her family history & poorly controlled diabetes considered the most common secondary risk factor(1). Insulin infusion is used to treat severe HTG if associated with AP or hyperglycemia. Low fat diet remains the cornerstone of maintenance management with oral administration of medium chain fatty acid or omega-3 acid ethyl esters has become part of management. Though safety for fibrates has not been well established yet; they may still be used in the later stages of gestation when benefits outweigh the risks(1,2). CONCLUSIONS:Severe gestational HTG is a rare but serious condition that can cause AP which can be challenging to diagnose & treat in pregnancy.

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