Extracorporeal membrane oxygenation (ECMO) can be useful in patients with severe acute respiratory distress syndrome (ARDS), when refractory hypoxia and respiratory acidosis limit the possibility to apply lung protective ventilation strategies. Some patients on ECMO may have such severe lung damage that they will not improve, leading to the dilemma when to withdraw this support. We describe the case of a young woman who developed ARDS due to a Streptococcus pyogenes pneumonia during pregnancy. After two weeks of conventional ARDS treatment with low tidal volume ventilation, prone positioning and high-dose steroids, further deterioration occurred after difficult to treat bilateral pneumothorax, and ultimately venovenous ECMO was initiated. Treatment was complicated by Enterococcus faecium bacteraemia, haemolysis, pulmonary haemorrhage and haematothorax. Over a long period, the pulmonary function remained extremely poor and lung transplantation had to be considered. However, after 108 days the patient could be weaned from the ECMO. Subsequently, she was weaned from the ventilator in six further weeks. She was transferred to a revalidation centre after a hospital stay of six months. The case shows that long-term ECMO treatment for ARDS can be successful. © 2015, Netherlands Society of Intensive Care. All rights reserved.