Severe cardiovascular instability, as indicated by the hemodynamic monitoring of the patient, with refractory shock in H1N1 infection, has not been reported so far in the literature. Acute lung injury and/or ARDS due to H1N1 virus could not be identified, as initial chest Xray and thorax CT were normal and oxygenation was not impaired (PaO 2 /FiO 2 ≥350) throughout the disease course. Bacterial infections, as potential causes of septic shock, were not diagnosed; serial blood, urine and BAL cultures were negative. The therapeutic approach was that of conventional septic shock, according to 2008 guidelines and resulted in patient recovery [14] .