CASE PRESENTATION: 17 y/o male-to-female transgender patient presented with progressive dyspnea, non-productive cough and pleuritic chest pain 2 days after injecting silicone for breast augmentation. On admission, the patient was tachycardic, tachypneic and required supplemental oxygen. She was noted to have decreased breath sounds, bilateral breast tenderness and ecchymotic lesions in the upper quadrant of left breast. Lab results revealed leukocytosis of 21,000 cells/µL & D-dimer of 1.29 µg/L. Initial CXR showed diffuse bilateral hazy airspace opacities with interstitial thickening. CT chest angiography was negative for acute emboli but showed patchy ground-glass opacities throughout both lungs. On the night of admission, the patient had several coughing paroxysms with oxygen saturation(O2sat) of 85-87% & multiple episodes of hemoptysis. 48 hours later, respiratory status worsened, initially requiring high flow oxygen, then BiPAP and ultimately 125mg IV methylprednisolone. Patient minimally improved & was emergently intubated. Post-intubation the O2sat remained at 80% on FiO2 of 100% and PEEP of 16cmH2O. Nitric oxide(NO) at 20ppm was added, but O2sat was still <90%. Repeat CXR showed worsening bilateral infiltrates. 5 hours post-intubation and NO administraton, hypoxemia and acidosis worsened. Subsequently, the patient was placed on VenoVenous(V-V) ECMO support & continued with pressure-controlled ventilation. Bronchoscopy post-ECMO showed fresh blood in both bronchi with hemorrhagic fluid return & cytology revealed rare clusters of reactive bronchial epithelial cells and alveolar macrophages. Patient was kept on IV steroids while unfractionated heparin was given for V-V ECMO. The patient's overall clinical status progressively improved & was successfully weaned off ECMO on day 5 and extubated on day 6.