Refractory ARDS with diffuse centrilobular nodules: did the patient smoke a tree?

A 22-year-old man with no relevant medical history except hashish use (10 joints a day) was admitted to the intensive care unit in December 2018 for refractory acute respiratory distress syndrome (ARDS). He presented dry cough and dyspnoea for 1 week. After intubation, veno-venous extracorporeal membrane oxygenation (VV-ECMO) was required because of severe hypoxemia and very low respiratory compliance (15 mL/cmH2O). Given the possibility of severe community-acquired pneumonia and influenza, urgent antibiotic therapy associating cephalosporin plus macrolid and …