RR is a 17-year-old previously healthy Hispanic male who presented to a community emergency room with a 1- week history of progressive worsening of shortness of breath, abdominal pain, diarrhea, and ageusia. Past medical history revealed a 3-months history of dry cough and 9 pounds unintentional weight loss for which he had not sought medical care. Pertinent positives include smoking cigarettes for two years and vaping nicotine and Delta-9-tetrahydrocannabinol for one year. Pertinent negatives include traveling outside of the country, or exposure to known contacts with COVID-19 or tuberculosis. Initial workup included testing for SARS CoV-2, which was undetected by real time-polymerase chain reaction (RT-PCR) from the nasopharynx. He was transferred to our hospital for further evaluation of respiratory distress where repeat SARS CoV-2 by RT-PCR was then detected. Additional laboratory studies revealed a white blood cell count (WBC) of 27,500 mm 3 with 84% neutrophils, 2% bands, and 10.1% lymphocytes. C- reactive protein (C-RP) and procalcitonin were elevated to 33 mg/dl and 3.14 ng/ml, respectively. Urine toxicology screen was positive for Delta-9-tetrahydrocannabinol metabolites. The initial chest radiograph demonstrated patchy bilateral opacities without focal consolidation (See Fig. 1 ).
A diagnosis of e-cigarette, or vaping, product-associated lung injury (EVALI) was also suspected in addition to COVID-19 given his history of vaping in the previous 90 days, respiratory symptoms alongside characteristic radiographic findings, consistent with the Centers for Disease Control and Prevention (CDC) definition. A chest computed tomography (CT) revealed patchy ground-glass pulmonary opacities and scattered opacities throughout both lungs, primarily in a perihilar and peripheral distribution (See Fig. 2 ).
The patient was admitted to the COVID-19 special isolation unit. Given the presence of oxyhemoglobin desaturation to 88%, the patient was placed on 1.5 L per minute (lpm) of oxygen via nasal cannula during admission with resolution of hypoxemia. Shortly after admission, the pulmonology team was consulted. With growing evidence that patients with COVID -19 with moderate to severe illness may have a favorable response to dexamethasone in association with evidence that patients with EVALI may benefit from glucocorticoid use, pulmonology recommended to start the patient on oral dexamethasone 6 mg daily. He demonstrated an excellent response to glucocorticoids with resolution of respiratory symptoms and was weaned to room air and discharged home on the second day of admission.
One day after hospital discharge, the patient returned to the emergency room with worsening chest pain and shortness of breath. Vital signs revealed a temperature of 38.5  C, respiratory rate of 39 and an oxyhemoglobin saturation of 91%, and the lung exam revealed clear breath sounds. Due to hypoxemia and tachypnea, he was admitted to the intensive care unit and started on 15 L of heated high flow nasal cannula (HHFNC) and supplemental oxygen (0.45 fraction of inspired oxygen). The infectious disease team was consulted and recommended a 5-day course of remdesivir and dexamethasone was continued for a total of 10 days. The patient was weaned to room air on the third day of admission. On day 4 of admission, repeat C-reactive protein level had decreased to 22.9 mg/dl, and repeat chest radiograph on day 7 showed improvement of patchy opacities. He could subsequently be discharged to home with follow up to his primary care provider and the pulmonary clinic.
Chest computed tomography with findings of patchy ground-glass pulmonary opacities and scattered opacities throughout both lungs, primarily in a perihilar and peripheral distribution.