On admission, she was in severe cardiovascular instability with hypotension (BP = 60/40 mmHg), tachycardia (HR = 130/min), tachypnea (RR = 30/min), hypothermia (< 35.5°C), along with oliguria and altered mental status. Oxygenation fraction PaO 2 /FiO 2 was over 350. No obvious site of infection could be identified. The initial chest X-ray was normal, as well as computed tomography of the thorax ( Figure 1 ). Heart ultrasound revealed mild diastolic dysfunction with preserved ejection fraction and no valvular disease. Concerning other organ involvement, there was mild prerenal azotemia (urea 94 mg/dl, creatinine 1.5 mg/dl) and severe liver impairment (alanine aminotransferase 2837 U/L, aspartate aminotransferase 3165 U/L).