CASE PRESENTATION: A 66-year old male diagnosed with metastatic esophageal cancer one year ago, presented with sudden-onset pleuritic chest pain. He had refused therapy for his esophageal cancer in the past and underwent palliative stenting 10 days prior. At presentation, he was found to be hypotensive (78/50 mm Hg), tachycardic (122 beats/min) and tachypneic (23/min). Electrocardiogram showed diffuse ST elevations (Fig. 1a), suggestive of pericarditis. Echocardiogram was suggestive of cardiac tamponade. Pericardiocentesis revealed frothy, turbid, foul-smelling fluid. Hemodynamics improved and patient was admitted to the critical care unit. Imaging studies showed hydropneumopericardium and bilateral pleural effusions (Fig. 1b) suggestive of an EPF. Blood cultures subsequently grew E. Coli and pericardial fluid cultures grew eikenella, streptoccus, candida and fusobacterium species. Broad spectrum antibiotics were initiated. The patient refused aggressive management and was transitioned to comfort care.