A patient in his 20s with Crohn’s disease (status: postileostomy) on no medications presented with 3 weeks of left-sided pleuritic chest pain and dyspnea. He was smoking one pack of cigarettes per week but denied illicit drug or alcohol use. He had no pets and denied recent travel or occupational exposures. On physical examination, he was afebrile but diaphoretic, tachycardic, tachypneic, with BP 113/58 mm Hg without pulsus paradoxus. The jugular venous pressure was elevated with distant heart sounds. The chest was clear. He had diffuse abdominal tenderness maximal over the right upper quadrant with no peritonism, and his ileostomy site was intact. ECG showed diffuse ST elevation and PR depression. Laboratory data were significant for the following: WBC count 31.7 with 19% bands, hemoglobin 8.2 g/dL, platelets 734, acute renal failure, negative cardiac enzymes, total bilirubin 4.1 mg/dL, alkaline phosphastase 229 units/L, aspartate aminotransferase 59 units/L, alanine aminotransferase 84 units/L, and lactic acidosis 3.3 mg/dL. CXR revealed massive cardiomegaly but clear lung fields. A transthoracic echocardiogram was performed showing a moderate to large pericardial effusion with evidence of increased intrapericardial pressure that did not meet criteria for tamponade, ejection fraction of 50%, and no vegetations. Pericardiocentesis was attempted but was unsuccessful with an apparent loculated effusion. Right-sided heart catheterization revealed no tamponade physiology. An abdominal CT scan was obtained, showing new hypodense areas occupying the entire left lobe and portions of the right lobe of the liver and thickening of the gallbladder wall with extension of the abscess through the diaphragm into the adjacent pericardial space (Fig 2). The patient was initiated on broad-spectrum antibiotics and taken to the operating room for a pericardial window and drainage of his liver. Foul-smelling, purulent fluid (1,000 mL) was drained from his pericardium, and 700 mL of similar appearing fluid was drained from his liver where a drain was placed. An intraoperative transesophageal echocardiogram did not show vegetations. Pericardial fluid, hepatic fluid, and blood cultures all grew S anginosus susceptible to penicillin (MIC, 0.064). No anaerobes, fungi, or mycobacteria were isolated. He was treated with IV ceftriaxone with a hepatic drain in place for 6 weeks with clinical improvement.