CASE PRESENTATION: A 59-year-old male with hypertension and heavy tobacco use was admitted to hospital due to high fever, chronic cough and dyspnea for two weeks. Patient appeared chronically ill. Patient was tachycardic at 100 beats/min, respiratory rate of 30/min, BP 100/50mmHg and oxygen saturation of 95% on 2 liter nasal cannula. Physical examination was normal except for increased AP chest diameter. Cardiac sounds were normal. Chest X-ray showed cardiomegaly and hyperinflated lungs. Electrocardiogram was normal except for sinus tachycardia. EKG Voltage was normal. BNP was 271, WBC was 43000 per microliter, Hb was 8.9gm/dl and platelet count was 50000. TSH was normal as was coagulation profile. CT scan of chest revealed moderate pericardial effusion and emphysematous changes. Bone Marrow biopsy showed findings consistent with Myelodysplastic syndrome of refractory anemia with excess blast type. Echocardiogram showed normal ejection fraction with 1 cm posterior pericardial effusion without evidence of tamponade. Next day due to worsening of dyspnea and pulsus paradoxus patient underwent repeat echocardiogram, which showed worsening of pericardial effusion with evidence of tamponade. He underwent surgical pericardial window with improvement. Pericardial fluid showed hemorrhagic effusion with blasts. Patient was initiated on chemotherapy with Azacitidine. Subsequent improvement led to his discharge home.