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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.

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