Case Presentation: A 22 year old woman with a history of poorly controlled type 1 diabetes mellitus complicated by gastroparesis (not on metoclopramide), stricturing Crohn’s disease status post ileocecectomy, severe malnutrition (BMI 12.98), opioid use disorder (on suboxone) presented as a transfer to the Cardiac Intensive Care Unit (CICU) with Influenza A infection, streptococcus pneumoniae bacteremia, cardiogenic and septic shock and acute respiratory distress syndrome (ARDS). On initial presentation, she was intubated and appeared severely cachectic, with coarse and scattered crackles on respiratory exam, and atrophic extremities with diffuse lanugo. As she was still hypotensive, she received vigorous fluid resuscitation and was started on pressors. Vancomycin (later discontinued), ceftriaxone and oseltamivir were given. Azithromycin was given as an anti-inflammatory agent. Labs were significant for elevated BNP, hemoglobin A1c of 14.5% and selenium deficiency. She had ARDS (Figure 1A), significantly reduced cardiac output (left ventricular ejection fraction (LVEF) 10% from 40% two days prior) and apical akinesis sparring the basal segments suggestive of stress cardiomyopathy. She underwent intra-aortic balloon pump (IABP) implantation with subsequent improvement in cardiac output on echocardiogram. She later had increasing abdominal distention with an abdominal X-ray showing dilated small bowel (Figure 1B) that was treated with bowel rest and nasogastric decompression per Surgery. On day three of hospitalization, the IABP was removed and she was successfully extubated and then transferred from the CICU. As evaluated by Psychiatry and Gastroenterology, her severe malnutrition was most likely secondary to untreated depression (started on escitalopram and olanzapine) and sustained nausea from untreated gastroparesis rather than an eating disorder. Her cardiac function returned to normal (LVEF 55-60%) and she was discharged on day 16. Prior to presentation, she had not been seen by an gastroenterologist or endocrinologist for a while. She did not test blood sugar regularly, use insulin regularly and had multiple previous hospitalizations for hyperglycemia. Conclusion: This case highlights the importance of transitioning care from pediatric to adult providers in medically complex young adults. While not directly culpable for her admission, her uncontrolled type 1 diabetes and severe malnutrition played a role in her illness by impairing her immune response and increasing her risk of infection. Young adults with type one diabetes should be closely followed during this transition if they already have an elevated hemoglobin A1c, comorbidities, or previous hospitalizations for hyperglycemia. As seen in this patient, both her weight and hemoglobin A1c worsened from ages 21-22 when she had incomplete follow-up (Figure 2). Recommendations for a successful transition include assessing readiness prior to transition, involving a team approach including mental health and social work, and following up after transition to adult medicine.