A 56-year-old woman of South Indian origin presented with 2 weeks of cough, fever, malaise and dyspnoea ,with no response to amoxicillin. She was generally well with mild hypertension, type 2 diabetes controlled with metformin, hypothyroidism and vitamin D deficiency. There were no other relevant exposures, previous imaging, lung function or other investigations. Initial observations: temperature 38.2°C, blood pressure 112/76 mm Hg, RR 24, SpO2 94% on 3 L/min of O2 via nasal cannulae. Examination of the chest revealed bilateral crackles. Chest X-ray on admission showed bilateral patchy consolidation to the mid zones (figure 1A). Figure 1 Radiology on admission, initiation of mechanical ventilation, initiation of ECMO, and discharge. Initial test results are shown below: White cell count 8.8×109/L (4–10). C-reactive protein 141 (