Background <p>Exogenous lipoid pneumonia, a form of pneumonia caused by the aspiration of lipid substances, is often associated with the use of mineral oil. Historically, cases have predominantly been reported in young children, elderly, or individuals with compromised physical strength or neurological disorders, with the majority presenting as mild or chronic conditions. Upon cessation of exposure to lipids, symptoms typically showed improvement.</p> Case presentation <p>We report a case of a previously healthy middle-aged man who developed respiratory failure and severe acute respiratory distress syndrome (ARDS) following the accidental aspiration of sewing machine oil, and a chest computed tomography (CT) scan revealed consolidations in both lungs, with local attenuation visible in the mediastinal window. Lipid vacuoles were observed in the bronchoalveolar lavage fluid, and Oil Red O staining was positive, confirming the diagnosis. In terms of treatment, invasive mechanical ventilation was provided, along with intermittent prone positioning ventilation, segmented alveolar lavage, and systemic corticosteroids as part of a comprehensive treatment approach. The patient’s oxygenation gradually improved, leading to stabilization, and follow-up chest CT three months later showed resolution of the lung lesions.</p> Conclusion <p>The diagnosis of exogenous lipoid pneumonia is based on a history of lipid exposure, chest imaging, and the presence of lipid-laden macrophages in bronchoalveolar lavage fluid. However, there is currently no established treatment protocol. For critically ill patients, life support measures are crucial during the early stages or peak of the disease.</p> Clinical trial number <p>Not applicable.</p>