After commencing caspofungin with voriconazole, WBC, ANC and C reactive protein (CRP) slowly decreased, while pulmonary function slightly improved. On day 19, a multidrug-resistant Pseudomonas aeruginosa was isolated from bronchoaspirate ( Figure 3 ). In spite of antibiotic reinforcement with levofloxacin, Pseudomonas aeruginosa antibiogram showed increased resistance to all antibiotics and to colimicine which was started on day 26. On day 28, a sudden increase in resistance on the return part of the circuit caused a massive thrombosis in the oxygenator. The entire circuit and the cannula were immediately changed and ECMO restarted within 2 hours. Following the development of pulmonary embolism, the gas exchange rapidly worsened and NOi had to be restarted. An echocardiographic assessment showed right ventricular dilatation, with paradoxical septal wall motion and pulmonary hypertension (systolic pressure 90mmHg). Prostacyclin and sildenafil improved the right heart function and effectively attenuated pulmonary hypertension. In the following days, WBC, ANC and CRP slowly decreased, while pulmonary function improved. Thirty days from ICU admission, ECMO was stopped, the patient rapidly restored her spontaneous ventilatory functions and she was extubated 10 days later. She was finally discharged from the ICU on day 44. At 16-month follow-up, the patient is alive and free from immunosuppressive drugs. At the time of last follow-up, Hb level was 13.5g/dL, reticulocyte count was 11 × 10 9 /L, with total bilirubin, lactic dehydrogenase and haptoglobin all within the normal ranges.