CASE PRESENTATION: A 39 year old female presented 3 weeks after POEM with cough, dyspnea, and weakness. She was afebrile, tachycardic and tachypneic. Physical exam revealed mild distress with tachypnea, distant heart sounds, and cool, mottled feet. Laboratory data (see table) was suggestive of sepsis. Initial CT of the chest and neck showed pneumopericardium. Initial upper GI gastrograffin series showed no evidence of extraluminal contrast. However, given her worrisome clinical presentation, a repeat CT chest was obtained, which revealed contrast in the pericardial space, confirming the leak. The patient underwent pericardial drainage and chest tube placement for parapneumonic effusion with improvement of her hemodynamic parameters. She had a protracted course in the ICU with vent-dependent respiratory failure requiring tracheostomy. She required broad spectrum antibiotics and inotropic support for left ventricular dysfunction from sepsis which subsequently resolved. She was weaned from the ventilator, decannulated and discharged home successfully, tolerating oral nutrition.