Chylotamponade in Pediatric Primary Mediastinal Large B-Cell Lymphoma

Chylotamponade involves rapid accumulation of chyle in the pericardium elevating the pericardial pressures above normal right heart filling pressures, and is extremely rare. A 12-y-old boy presented to the emergency with complaints of facial puffiness for 1 mo and breathing difficulty for 1 wk. The neck veins were distended, and the heart sounds were muffled. A chest CT demonstrated a large anterior mediastinal mass with pleural and pericardial effusions. Echocardiography confirmed cardiac tamponade. Pericardiocentesis revealed chylopericardium. He was placed on a chyle leak diet, and the drain was removed after 48 h. Biopsy of the mediastinal mass revealed a primary mediastinal B-cell lymphoma. He was successfully managed with chemotherapy. The index case demonstrates how prompt identification and management of chylotamponade and treatment of the underlying cause can lead to good clinical outcomes.

Pericardial Manifestations of Thyroid Diseases

PURPOSE OF REVIEW

Thyroid disorders, especially hypothyroidism, are known to be associated with pericardial diseases. The aim of this paper is to review the current knowledge of the pericardial manifestations of hypothyroidism and hyperthyroidism.

RECENT FINDINGS

Many reports have described associations between dysthyroidism, which encompasses hypothyroidism and hyperthyroidism, and several pericardial diseases, including acute pericarditis, constrictive pericarditis, pericardial effusion, and tamponade. The diagnosis of dysthyroidism-induced pericardial diseases consists of a combination of thyroid blood levels that fall outside of the normal range and the exclusion of other causes. Treatment of the thyroid disorder is key, along with treatment of the pericardial disease as recommended by the guidelines. Early recognition of the thyroid disorder is key in patients with pericardial diseases, since treating the underlying cause should assist resolution of the pericardial issues and ideally prevent recurrence and possible future complications of suboptimally treated pericarditis or pericardial effusions.

Yellow nail syndrome accompanied by minimal-change nephrotic syndrome: A case report

BACKGROUND

In most cases of yellow nail syndrome (YNS), the classic triad of yellow nails, lymphedema and respiratory manifestations rarely manifest simultaneously. Therefore, diagnosis is delayed or frequently missed.

CASE SUMMARY

We report a 62-year-old YNS patient presenting with bilateral pleural, pericardial and peritoneal effusions who, 2 mo later, developed minimal-change nephrotic syndrome. After treatment with vitamin E, clarithromycin and prednisone for 3 mo, effusions in the chest, pericardium and abdominal cavity decreased while urine protein levels returned to within normal ranges.

CONCLUSION

Clinicians should consider the possibility of YNS for patients presenting with multiple serous effusions and nephrotic syndromes.

Myopericarditis with hemorrhagic pericardial effusion following BNT162b2 mRNA COVID-19 vaccine

Since the onset of the COVID-19 pandemic, to date, around 385 million cases have been diagnosed worldwide leading to an estimated 5.7 million death toll. Mass vaccination campaigns have been conducted to control the spread of infection with the most commonly used vaccines being Pfizer-BioNTech and Moderna. However, the adverse effects of vaccination have not yet been fully investigated. Of concern are some serious cardiovascular events such as myocarditis, pericarditis, or perimyocarditis development post-vaccination. Hemorrhagic pericardial effusion has not been reported. However, we report a case of myopericarditis with a hemorrhagic pericardial effusion that developed two weeks following BNT162b2 mRNA COVID-19 vaccination. We performed a complete workup identifying the underlying cause that did not yield any significant findings. Our patient was treated with colchicine and ibuprofen, and he made a full recovery. A follow-up cardiovascular magnetic resonance imaging (CMR) showed no signs of active inflammation.

Pericardial effusion in giant cell arteritis is associated with increased inflammatory markers: a retrospective cohort study

OBJECTIVE

Giant cell arteritis (GCA) is the most frequent vasculitis affecting adults aged > 50 years. Cardiac involvement in GCA is considered rare, and only a few cases of pericarditis have been reported. The aim of this study was to determine the characteristics and prognosis of GCA patients suffering from pericardial involvement at diagnosis.

METHODS

We conducted a single-centre, retrospective chart review of patients with GCA in internal medicine departments (from 2000 to 2020). Patients were identified through a centralized hospital database. We retrospectively collected demographic, clinicobiological, histological, imaging, treatment and outcome data. Patients with pericardial effusion, defined as an effusion visible on the CT-scan performed at GCA diagnosis were compared to those without pericardial involvement.

RESULTS

Among the 250 patients with GCA, 23 patients (9.2%) had pericardial effusion on CT-scan. The comparison between the groups revealed similar distribution of age, gender, cranial symptoms and ocular ischaemic complications. Patients with pericardial effusion had a higher frequency of weight loss. They also had lower haemoglobin levels and higher platelet levels (p = 0.006 and p = 0.002, respectively), and they more frequently had positive temporal artery biopsy. There were no differences concerning the treatment, relapses, follow-up duration or deaths.

CONCLUSIONS

This case series sheds light on GCA as a cause of unexplained pericardial effusion or symptomatic pericarditis among adults aged > 50 years and elevated inflammatory biological markers. Fortunately, pericardial involvement is a benign GCA manifestation. In that context, the search for constitutional symptoms, cranial symptoms and associated signs of polymyalgia rheumatica is crucial for rapidly guiding GCA diagnosis.

Cardiovascular Diseases in Pet Birds: Therapeutic Options and Challenges

Cardiovascular disease, including congestive heart failure, pericardial disease, and atherosclerosis, is becoming increasingly better recognized in companion birds. A wide range of medications is available to treat these conditions, including diuretics, vasodilators, positive and negative inotropes, antiarrhythmic agents, and pentoxifylline. This review systematically discusses each of these drug classes and their potential applications in avian species. Although treatment approaches remain largely empirical and extrapolated from small animal and human medicine, the management strategies presented here have the potential to both maintain quality of life and extend survival time for the avian cardiac patient.

Pulmonary hypertension among maintenance hemodialysis patients in Somalia: a hospital-based observational study

BACKGROUND

This study aims to examine the prevalence and related factors of pulmonary hypertension (PHT) in patients on hemodialysis (HD) at the only referral institution in Somalia. A total of one hundred and forty-three patients  who had received regular HD therapy for at least three months and underwent transthoracic echocardiography (TTE) were included in the study. Patients with a systolic pulmonary artery pressure (sPAP) value > 35 mmHg at rest on TTE were considered having PHT. The relationship of TTE parameters, demographic, and clinic characteristics of participants with PHT were evaluated.

RESULTS

The number of patients with PHT was 73 (51%). The mean age was 54.2 ± 18.4 years. The majority of patients were 65 years of age or older. (n: 46, 32.2%) and 65 (45.5%) were male. Median sPAP was found to be 35 mmHg. Systolic pulmonary artery pressure was positively correlated with right atrium (RA) diameter (r: 0.6, p < 0.001) and negatively correlated with left ventricular ejection fraction (LVEF) (r: - 0.4, p < 0.001). In addition, LVEF, RA diameter, presence of pericardial effusion (PE) were found to be independent predictors of PHT.

CONCLUSIONS

Pulmonary hypertension has a relatively high prevalence in end-stage renal disease (ESRD) patients on regular HD. Besides, the presence of PE and certain right and left heart parameters were independently associated with PHT.

Echocardiographic changes in anorexia nervosa: a pathophysiological adaptation or a disease?

Anorexia Nervosa is one of the most common form of eating disorders. Cardiac involvement occurs in approximately 80% of patients. Few reports focused on the association between body weight fluctuations and echocardiographic abnormalities, considering linear measurements. We describe echocardiographic and clinical features among male and female patients with anorexia nervosa and the effect of weight gain on these parameters. We performed a single center, retrospective study of patients followed at a dedicated multidisciplinary Unit. The study population consisted of 81 patients, mean age 25 ± 11 years, 94% female. Median body mass index was 14.4 kg/m² (25th-75th percentile 12.7-15.6 kg/m²). Patients with body mass index below the median value had more often pericardial effusion, smaller left ventricular mass and left ventricular end-diastolic volume and thinner interventricular septum. However, when indexed to body surface area, left ventricular mass and volumes were within the normal range in 90% of population. Patients with pericardial effusion showed mitral valve abnormalities and lower values of white blood cells and platelets, although within normal limits. Presence of pericardial effusion was not related to inflammatory parameters or low plasma protein levels. In 39 patients who displayed weight gain during a median follow-up of 189 days (25th-75th percentile 47-471), increased left ventricular mass, interventricular septum thickness, white blood cells and platelet count and decreased pericardial effusion were observed. Patients with anorexia nervosa have a specific echocardiographic pattern which seems to be proportional to the body size, suggesting a pathophysiological adaptation to the lack of substrates.

Tuberculous pericarditis-a silent and challenging disease: A case report

BACKGROUND

Tuberculous pericarditis (TP) remains a challenge for endemic countries. In developing countries, one to two percent of patients with pulmonary tuberculosis develops TP.

CASE SUMMARY

A 49-year-old woman presented with dyspnea, chest pain and dry cough. On physical examination, veiled heart sounds were found. The electrocardiogram showed low-voltage complexes and the transthoracic echocardiography revealed a large and free-looking pericardial effusion. The patient was taken for an open pericardiotomy. The pericardial fluid revealed high levels of adenosine deaminase and Ziehl-Neelsen stain showed acid-fast bacilli. Polymerase chain reaction study for Mycobacterium tuberculosis in pericardial fluid was positive. The patient received tetra conjugate management with adequate clinical response after the first week of treatment and resolution of fever and chest pain.

CONCLUSION

In cases of TP, obtaining pericardial fluid and/or pericardial biopsy is the most efficient strategy to confirm the diagnosis. Early diagnosis of this entity will allow physicians to initiate timely treatment, avoid complications and improve the patient's clinical outcome, so we consider the description of this case pertinent and its review in the literature.

Pericardiocentesis: ultrasound guidance is essential

Background

Pericardial effusion is a common entity which may have important implications in patient’s prognosis. In several cases, pericardiocentesis is indicated for diagnostic and/or therapeutic purposes.

Case presentation

A blind pericardiocentesis failed in a 95-year-old woman admitted to the emergency department with a large pericardial effusion incidentally diagnosed in the ambulatory setting. Ultrasound-guided pericardiocentesis aided in easily accessing to the pericardial cavity, without periprocedural complications.

Conclusions

Ultrasound-guided pericardiocentesis is simple, safe and effective, and should replace the blind technique. This procedure should be part of the armamentarium of ultrasound-guided practices of emergency or critical care physicians.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13089-022-00259-5.

Development and validation of a risk score for predicting pericardial effusion in patients undergoing leadless pacemaker implantation: experience with the Micra transcatheter pacemaker

AIMS

There is limited information on what clinical factors are associated with the development of pericardial effusion after leadless pacemaker implantation. We sought to determine predictors of and to develop a risk score for pericardial effusion in patients undergoing Micra leadless pacemaker implantation attempt.

METHODS AND RESULTS

Patients (n = 2817) undergoing implant attempt from the Micra global trials were analysed. Characteristics were compared between patients with and without pericardial effusion (including cardiac perforation and tamponade). A risk score for pericardial effusion was developed from 18 pre-procedural clinical variables using lasso logistic regression. Internal validation and future prediction performance were estimated using bootstrap resampling. The scoring system was also externally validated using data from the Micra Acute Performance European and Middle East (MAP EMEA) registry. There were 32 patients with a pericardial effusion [1.1%, 95% confidence interval (CI): 0.8-1.6%]. Following lasso logistic regression, 11 of 18 variables remained in the model from which point values were assigned. The C-index was 0.79 (95% CI: 0.71-0.88). Patient risk score profile ranged from -4 (lowest risk) to 5 (highest risk) with 71.8% patients considered low risk (risk score ≤0), 16.6% considered medium risk (risk score = 1), and 11.7% considered high risk (risk score ≥2) for effusion. The median C-index following bootstrap validation was 0.73 (interquartile range: 0.70-0.75). The C-index based on 9 pericardial effusions from the 928 patients in the MAP EMEA registry was 0.68 (95% CI: 0.52-0.83). The pericardial effusion rate increased significantly with additional Micra deployments in medium-risk (P = 0.034) and high-risk (P < 0.001) patients.

CONCLUSION

The overall rate of pericardial effusion following Micra implantation attempt is 1.1% and has decreased over time. The risk of pericardial effusion after Micra implant attempt can be predicted using pre-procedural clinical characteristics with reasonable discrimination.

CLINICAL TRIAL REGISTRATION

The Micra Post-Approval Registry (ClinicalTrials.gov identifier: NCT02536118), Micra Continued Access Study (ClinicalTrials.gov identifier: NCT02488681), and Micra Transcatheter Pacing Study (ClinicalTrials.gov identifier: NCT02004873).

Rituximab therapy in pericarditis associated with rheumatoid arthritis

In rheumatoid arthritis, pericarditis is commonly asymptomatic, but rarely, it progresses to a morbid complication, like cardiac tamponade or restrictive pericarditis. Current studies have indicated that conventional drugs have limited ability to reverse these lethal conditions. To date, invasive surgical measures remain the only definitive therapy for patients who are unresponsive to drugs. Recently, anti-tumor necrosis factor-α and anti-interleukin-1 antibody-based drugs have shown limited success. Consequently, given the importance of pericarditis, we need new treatment methods. Here, we describe a patient with rheumatoid arthritis and effusive pericarditis, which progressed to life-threatening cardiac tamponade. The patient responded very well to rituximab. Thus, rituximab represents a potential new therapy for this rarely treated complication of rheumatoid arthritis.

Right atrium angiosarcoma with feeding vessels from right coronary artery: a case report

BACKGROUND

Primary cardiac angiosarcoma is a rare primary cardiac malignancy. Biopsy of such vascular-rich tumours may result in serious complications.

CASE SUMMARY

This is a case of a 43-year-old woman who presented with syncope. According to clinical history, she initially had massive pericardial effusion, with an uncertain aetiology. Multimodality imaging at our hospital revealed a cauliflower-like tumour in the right atrium. Coronary angiography results confirmed multiple feeding vessels from the right coronary artery to the tumour. Thoracoscopic biopsy resulted in a massive bleeding requiring haemostasis via thoracotomy. Histopathological examination of the specimen showed an angiosarcoma with atypical cells and spindle cells in a myxomatous background. Treatment with systemic targeted therapy and chemotherapy was initiated, and the patient is still under active treatment.

DISCUSSION

Cardiac angiosarcomas most commonly arise from the right atrium and may be hard to detect with transthoracic echocardiography. Biopsy of primary cardiac angiosarcomas requires careful planning because they are highly vascularized. Currently, no guidelines regarding the treatment of such tumours exist, and a multidisciplinary treatment is needed.

POEMS syndrome causing left ventricular hypertrophy, myocardial dysfunction, and pericardial effusion: a case report

Background

POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, M-protein, skin changes) is a paraneoplastic syndrome caused by a plasma cell proliferative disorder. Characteristics of POEMS syndrome include elevated pro-inflammatory and angiogenic cytokine levels that lead to multi-organ dysfunction. Patients have a variety of initial symptoms, but cardiac involvement is not common.

Case summary

We report a case of a 31-year-old Chinese woman with chief complaints of chest pain and dyspnoea who was diagnosed with POEMS syndrome. The cardiovascular system in the case study patient was characterized by pericardial effusion, enlarged left atria, abnormal myocardial segmental deformation, left ventricular hypertrophy, pulmonary hypertension, and increased glucose metabolism in the left and right ventricular myocardium. The pericardial effusion diminished, while cardiac function, left ventricular wall thickness, and pulmonary hypertension gradually returned to normal with dexamethasone and bortezomib treatment.

Discussion

This case suggests that cardiovascular system damage may be related to systemic diseases. Cardiovascular system damage caused by POEMS syndrome is recoverable after chemotherapy treatment. Echocardiography readily visualizes the changes in the heart of a patient with POEMS syndrome, clearly reflecting the changes in the structure and function of the heart before and after treatment.

Prognostic Significance of Controlling Nutritional Status Score (CONUT) in Patients Undergoing Pericardiocentesis

BACKGROUND

Malnutrition is associated with a poor prognosis in cardiovascular diseases, however the prognostic impact of the Controlling Nutritional Status (CONUT) score in patients with pericardial effusion (PE) is not known.

METHODS

This was a retrospective study conducted among 301 consecutive patients with PE who underwent pericardiocentesis. CONUT score was calculated from serum albumin level, total cholesterol level and lymphocyte count. The prognostic role of admission CONUT score on long-term mortality was evaluated.

RESULTS

The patients were divided into two groups according to long-term mortality. A total of 131 patients died during follow-up. In multivariable regression analysis, chronic heart failure [hazard ratio (HR): 3.21, 95% confidence interval (CI): 1.18-8.70, p < 0.01], malignancy (HR: 5.67, 95% CI: 3.34-9.63, p < 0.01) and CONUT score (HR: 1.21, 95% CI: 1.10-1.33, p < 0.01) were found to be independent predictors of long-term mortality. CONUT score was significantly higher in the patients who died (5.8 ± 2.4 vs. 3.6 ± 2.2, p < 0.01). In receiver operating characteristics analysis, a CONUT score ≥ 4.5 predicted long-term mortality with 66% sensitivity and 69% specificity (area under curve: 0.73, 95% CI: 0.67-0.79, p < 0.01).

CONCLUSIONS

In patients with PE, CONUT score is an independent prognostic factor for mortality.

Acute severe pericarditis secondary to rodenticide intoxication in a dog

Background

Pericardial effusions are well described in dogs; however, their association with rodenticide intoxication in the canine population is not widely described.

Case Description

An adult mixed-breed dog was presented for 1-day history of anorexia and cough. Thoracic radiographs revealed moderate generalized cardiomegaly with globoid-shaped cardiac silhouette and mild bilateral pleural effusion. Echocardiography showed mild tamponating pericardial effusion and diffuse severe thickened pericardium. Compete blood count and blood chemistry at presentation were not specific. A coagulation profile was completed and showed severe prolongation of prothrombin time and partial thromboplastin time. Intravenous therapy with vitamin K was started at 5 mg/kg BID and on follow-up echocardiography performed 12 hours later there was evidence of complete regression of the pericardial thickening and pericardial effusion.

Conclusion

To the authors' knowledge, this is the first case report describing severe pericardial thickening, constrictive pericarditis, and cardiac tamponade secondary to spontaneous anticoagulant-induced hemopericardium in dogs.

Prognostic Value of Pericardial Effusion Size in Patients with Acute Heart Failure

BACKGROUND

Pericardial Effusion (PEf) can occur with Acute Heart Failure (AHF).

OBJECTIVE

To evaluate the effect of PEf size on the prognosis of patients with AHF.

METHODS

According to the maximum size of PEf, all patients were divided into five groups. The primary outcome was in-hospital mortality. The independent effect of PEf size was determined by binary logistic regression analysis. The curve in line with the overall trend was drawn by local weighted regression (Lowess).

RESULTS

We included 192 patients with AHF complicated by PEf. As PEf size increased, in-hospital mortality increased significantly (Group 5 vs. Group 1: 34.8 vs. 8.9% p=0.042). After adjusting for confounders, there was no significant association between PEf groups and in-hospital mortality (Group 5 vs. Group 1: odd ratio (OR), 95% confidence interval (CI): 2.72, 0.41-18.22, p=0.298). However, when PEf size was analysed as a continuous variable, an independent association between increased risk of inhospital mortality and PEf size was observed (OR, 95% CI: 1.08, 1.00-1.16, p=0.037). The Lowess curve showed a positive relationship between PEf size and in-hospital mortality. Furthermore, as PEf groups increased, the length of hospital stay (Group 5 vs. Group 1 median and interquartile range: 16, 14-21 vs. 13, 8-17 days, p<0.001) was significantly prolonged. An association between PEf size with acute kidney injury (AKI) was not observed.

CONCLUSION

The PEf size was independently associated with the increased risk of in-hospital mortality in patients with AHF.

Efficacy of Short-Term Oral Prednisolone Treatment in the Management of Pericardial Effusion Following Pediatric Cardiac Surgery

A standard treatment for pericardial effusion without cardiac tamponade after pediatric cardiac surgery has not been established. We evaluated the efficacy of short-term oral prednisolone administration, which is the initial treatment for postoperative pericardial effusion without cardiac tamponade at our institution. Between October 2008 and March 2020, 1429 pediatric cardiac surgeries were performed at our institution. 91 patients required postoperative treatment for pericardial effusion. 81 were treated with short-term oral prednisolone. Pericardial effusion was evaluated using serial echocardiography during diastole. Pericardial drainage was performed for patients with circumferential pericardial effusion with a maximum diameter of ≥ 10 mm or signs of cardiac tamponade. Short-term oral prednisolone treatment was administered to patients with circumferential pericardial effusion with a maximum diameter of < 10 mm or localized pericardial effusion with a maximum diameter of ≥ 5 mm. Patients with localized pericardial effusion with a maximum diameter of < 5 mm were observed. Prednisolone (2 mg/kg/day) was administered orally for 3 days, added as needed. Short-term oral prednisolone treatment was effective in 71 cases and 90% of patients were regarded as responders. The remaining patients were deemed non-responders who required pericardial drainage. Overall, 55 responders were deemed early responders whose pericardial effusion disappeared within 3 days. There were no cases of deaths, infections, or recurrence of pericardial effusion. The amount of drainage fluid on the day of surgery was higher in the non-responders. In conclusion, short-term oral prednisolone treatment is effective and safe for treating pericardial effusion without cardiac tamponade after pediatric cardiac surgery.

The Efficacy, Safety, and Side Effects of Intrapericardial Triamcinolone Treatment in Children with Post-surgical Pericardial Effusion: A Case Series

Intrapericardial triamcinolone can be used to treat chronic pericardial effusion (PE) in adults; however, pediatric data are lacking. In this case series we aim to evaluate the efficacy, safety, and side effects of intrapericardial triamcinolone in children with PE. The incidence and treatment of post-surgical PE from 2009 to 2019 were determined using the institutional surgical database and electronic patient records. Furthermore, a retrospective analysis of efficacy, safety, and side effects of intrapericardial triamcinolone treatment for chronic post-surgical PE was performed. The incidence of postoperative PE requiring treatment was highest after atrial septal defect (ASD) closure when compared to other types of cardiac surgery (9.7% vs 4.3%). Intrapericardial treatment with triamcinolone resolved pericardial effusion in 3 out of 4 patients. All patients developed significant systemic side effects. Surgical ASD closure is associated with an increased risk of development of PE requiring treatment. Intrapericardial triamcinolone is an effective treatment for chronic postoperative PE in children, but is always associated with significant systemic side effects. Close monitoring and treatment of adrenal insufficiency are mandatory in these cases.

Leadless Pacemaker Perforations: Clinical Consequences and Related Device and User Problems

Background

Cardiac perforation during leadless pacemaker implantation is more likely to require intervention than perforation by a transvenous lead. This study reports the consequences of Micra pacemaker perforations and related device and operator use problems based on information the manufacturer has submitted to the Food and Drug Administration (FDA).

Methods

FDA's Manufacturer and User Facility Device Experience (MAUDE) database was searched for Micra perforations. Data extracted included deaths, major adverse clinical events (MACEs), and device and/or operator use problems.

Results

Between 2016 and July 2021, 563 perforations were reported within 30 days of implant and resulted in 150 deaths (27%), 499 cardiac tamponades (89%), 64 pericardial effusions (11%), and 146 patients (26%) required emergency surgery. Half of perforations were associated with 139 (25%) device problems, 78 (14%) operator use problems, and 62 (11%) combined device and operator use problems. Inadequate electrical measurements or difficult positioning were the most frequent device problems (n = 129); non‐septal implants and perforation of other structures were the most frequent operator use problems (n = 69); a combined operator use and device problem resulted in 62 delivery system perforations. No device or operator use problem was identified for 282 perforations (50%), but they were associated with 78 deaths, 245 tamponades, and 57 emergency surgeries.

Conclusion

The Micra perforations reported in MAUDE are often associated with death and major complications requiring emergency intervention. Device and use problems account for at least half of perforations. Studies are needed to identify who is at risk for a perforation and how MACE can be avoided or mitigated.

Large hemorrhagic pericardial effusion with cardiac tamponade in a 16-year-old adolescent in an endemic area of tuberculosis: a case report

Pericardial effusion complicated by cardiac tamponade is a medical emergency. Large pericardial effusion and tamponade are rare in childhood. Tuberculosis remains a major cause of pericardial effusion in endemic areas. A 16-year-old adolescent with no significant past history was admitted to the medical unit of the Buea Regional hospital in the South West region of Cameroon for heart failure after presenting with abdominal distension, shortness of breath and fever of two weeks duration. Echocardiographic study during admission revealed a large pericardial effusion (27mm in thickness) with echocardiographic signs of tamponade. Echocardiographic guided pericardiocentesis was performed through a sub-xiphoid route and about 500 cc of heavily stained blood fluid that was not coagulating was drained. Pericardial fluid analysis for acid fast bacilli was negative. There was no evidence of malignancy. A strong suspicion of tuberculosis was made and he was started on anti-tuberculosis medications for presumptive hemorrhagic tuberculous pericarditis. Patient was asymptomatic during follow up and repeat echocardiographic examinations showed no re-accumulation of pericardial fluid. Tuberculosis should be considered as the etiology of pericardial effusion in endemic areas although the identification of mycobacterium is challenging in these settings.