Chest radiograph showed low lung volumes, with patchy air-space disease consistent with multifocal pneumonia (Figure 1 ). Intravenous azithromycin (500 mg twice daily), levofloxacin (500 mg twice daily) and oral oseltamivir (150 mg twice daily) were administered. Within 18 hours after arrival, tachypnea and hypoxemia (PaO 2 : 58 mm Hg, while breathing 50% oxygen) increased further requiring intubation and mechanical ventilation. Hypotension and renal failure developed; methylprednisolone and vasopressors were administered.