A 68 year old man was seen in clinic for progressive fatigue, dyspnoea on exertion, and cough which was progressive over one week. He denied any chest pain. He was being treated on a protocol for metastatic renal cell carcinoma. The patient initially had a chest radiograph taken, which revealed blunting of both costophrenic angles and an enlarged pericardial silhouette (fig 1). To evaluate the pericardial fluid and to rule out progressive disease computed tomography of the chest was performed. This demonstrated bilateral pleural effusions (arrowhead) and a moderate pericardial fluid collection (arrow) with suggestion of compression of the cardiac contours (fig 2). The patient underwent an urgent transthoracic two dimensional echocardiogram, which showed a moderate circumferential pericardial effusion and significant end diastolic right atrial (arrow) and ventricular (arrowhead) collapse consistent with cardiac tamponade physiology (fig 3). The patient was taken to the operating room, where an emergent subxiphoid pericardiostomy was performed.

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Figure 1

 Chest radiograph demonstrating blunting of both costophrenic angles and an enlarged pericardial silhouette.

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Figure 2

 Computed tomography: arrow demonstrates pericardial fluid collection; arrowhead demonstrates pleural fluid collection.

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Figure 3

 Two dimensional echocardiogram: arrow demonstrates right end diastolic atrial collapse; arrowhead demonstrates right end diastolic ventricular collapse, consistent with tamponade physiology.

Five hundreds millilitres of bloody fluid under pressure were evacuated without complication. The patient’s symptoms resolved and he was discharged to home without recurrence of the circumferential pericardial effusion.