Summary

A 67-year-old man presented with 3 months of exertional dyspnoea and 1 week of oedema. Examination revealed elevated neck veins, pulsus paradoxus, muffled heart sounds, decreased breath sounds and pedal oedema. Transthoracic echocardiogram (TTE) demonstrated cardiac tamponade, and chest X-ray showed pleural effusion. Pericardiocentesis, thoracocentesis, laboratory investigations and CT did not elucidate an underlying aetiology. Three weeks later, he presented with recurrent cardiac tamponade and pleural effusion. Pericardial window histology was benign. Pleural and pericardial fluids were again unrevealing. Three months later, he presented with worsening congestive heart failure. TTE, cardiac catheterisation and cardiac MRI were consistent with constrictive pericarditis. Preoperative workup did not identify an underlying cause. The patient underwent subtotal pericardiectomy. Intraoperative frozen section indicated malignancy. Pathology confirmed metastatic poorly differentiated signet ring adenocarcinoma of intestinal origin. He died 4 days postoperatively from multiorgan failure.