Following admission to ICU she rapidly became hypotensive, hypoglycaemic, coagulopathic and more anaemic. A possible basis for this could have been the systemic manifestations of a "cytokine storm" associated with MCD; increased expression of IL-6 is typical of MCD. Vasopressor and inotropic support with noradrenaline and dobutamine was required to maintain an adequate mean arterial pressure (MAP). Because of rapidly escalating requirements for noradrenaline she received a continuous infusion of hydrocortisone (10 mg/h) as per local departmental protocol, to treat probable relative adrenal insufficiency. Empirical antibiotics and antifungal agents were given to treat sepsis as a potential cause for ensuing multi-organ dysfunction, and she required a continuous infusion of 20% dextrose for refractory hypoglycaemia. To treat her acute renal failure and profound metabolic acidosis (serum lactate of 18.5 mmol/L), haemofiltration was undertaken with large volume 5 litre cycles (~90 ml/kg/hour) of lactatefree replacement fluid. This strategy was adopted to target early shock reversal and removal of IL-6, increased expression of which is a hallmark feature of MCD.