CASE PRESENTATION: A 33 year old male with past medical history of Down syndrome and asthma, presented to our facility with acute shortness of breath. Radiography revealed bilateral infiltrates and laboratory data was significant for leukocytosis, acute kidney injury and an elevated alveolar-arterial gradient.The patient required intubation for acute respiratory failure, but remained hypoxic necessitating initiation of a V-V ECMO. Bronchoscopy with bronchoalveolar lavage was performed. Bacterial,mycobacterial and fungal cultures were negative except viral cultures being positive for metapneumovirus.He was maintained on ECMO and ventilator support until his oxygen requirements gradually improved. He eventually had a tracheostomy and was discharged to a long term acute care facility after two month of hospital stay.