44 Year old male with a history of diffuse B-cell lymphoma s/p chemotherapy on surveillance, T1DM, hypothyroidism who had been dyspneic since 11/18. COVID swab + since 11/22 and admitted 11/27 with worsening dyspnea and cough. Patient is vaccinated for COVID (Moderna) but given immunosuppression is unlikely to have developed an adequate immune response. Treated with Remdesivir (completed 5 days 12/2) and 10 days of dexamethasone 6mg-completed 12/7. On 12/2 d/w hematology oncology who advised appropriate for baricitinib despite history of diffuse B-cell lymphoma; restarted 12/6-12/16. On 12/3 patient suddenly increased oxygen requirement to 45L of 100% FiO2 on HFNC. Work of breathing also increased so patient transferred to ICU 12/3. Dexamethasone restarted 12/5, then transitioned to stress dosing of hydrocortisone. Patient acutely decompensated early morning on 12/8. Oxygen saturation dropped after a coughing fit and was unable to normalize past 70%. Decision was made to intubate patient. Patient fevered to 39C. CT head was unremarkable. CT abd/pelvis 12/8 was unremarkable. CTPE showed nonocclusive right lower basilar segmental and subsegmental pulmonary emboli, trace right pneumothorax with moderate pneumomediastinum and subcutaneous neck emphysema. Oxygen saturation not improving so decision was made to place R. chest tube on 12/9. Patient continued to be unstable from a respiratory standpoint, requiring replacement of ET tube 12/10 due to position 8cm above carina, and R. chest tube repositioning 12/10 after routine AM CXR showed large R. pneumothorax reaccumulation. S/p Inhaled nitic oxide 12/10. Patient underwent bronchoscopy per ID recommendation on 12/10, s/p treatment with vancomycin, voriconazole.  On 12/10 evening, patient had continued desaturation with Sp02 of 63% so started on VV ECMO started. Cannula placed in R. IJ and R. femoral vein. CT head 12/10 done due to unequal pupils was unremarkable. CT chest/abd/pelvis done 12/10 with several findings, notably new signs of infectious/inflammatory gastroenteritis and pneumoperitoneum predominantly over the cecum, but no evidence of perforation. Patient required several blood product transfusions after ECMO initiation. Heparin ggt changed to argatroban 12/11 due to concern for HIT however HIT panel resulted negative on 12/11 . Patient continues to have neutropenia, heme/onc following. Review of smear confirms thrombocytopenia, atypical lymphocytes associated with Covid suggesting stressed marrow recommended that at this time no role for IVIG. Patient underwent bronchoscopy on 12/15 with some whitish secretions in the basal segments of the lower lobe which were suctioned out.  Chest tube was removed on 12/15 with resolving pneumothorax on repeat CXR on 12/16.  Difficulty weaning off sedation due to agitation and coughing fits. Increasing phenylephrine use on 12/19 (up to 40 to keep MAP>66), infection work up was initiated. Tracheostomy performed 12/20. On 12/21, patient had worsening of unequal pupils along with a decrease in GCS (9 to 3). He was sent for a head CT which showed no acute intracranial abnormality. He began following commands at approximately 10:20am, but had to go up on sedation as he became agitated with an increase in BP and HR. Pneumomediastinum still present. Femoral line placed and argatroban restarted. Blood pressure dropped overnight 12/21 and urine output decreased the following morning. He required a unit of blood on 12/21pm and 12/22am to maintain hemoglobin >8 as per ECMO protocol. Blood cultures showing Candida lusitaniae on 12/23, began micafungin per pharmacy recommendations for dosing.  12/28, added epinephrine gtt due to worsening shock.  Also started lactulose due to elevated ammonia.  TTE 12/26 showed dilated right ventricle.  Started lasix gtt 12/28.  Started ceftazidime 12/28 due to concern for multi drug resistant gram neg bacteremia, resistant to meropenem. Had acutely worsening severe transaminitis and hyperammonemia and ID recommended discontinuing micafungin.  Transaminitis improving, so micafungin restarted. Family elects for comfort care on 1/10/21. Patient died on 1/10/21 at 1428