A 38 year old white man presented to the emergency department with a three month history of progressively worsening shortness of breath. He had also experienced other vague symptoms over the same period, including muscle aches, weakness, pains associated with fatigue, and noticeable weight loss. Having previously been fit and well, he was now struggling to climb the stairs at home. The onset of symptoms coincided with an episode of food poisoning; he denied any recent travel.On clinical examination he had quiet heart sounds, with a raised jugular venous pressure, which rose on inspiration. He showed signs of haemodynamic compromise and shock, with a heart rate of 115 beats/min, blood pressure of 105/75 mm Hg but no postural drop, respiratory rate of 24 breaths/min, and oxygen saturations of 95% on room air. Chest radiography (fig 1) and electrocardiography showed classic changes. The results of these investigations prompted immediate point of care transthoracic echocardiography (fig 2). After consent, he was promptly admitted to the cardiac catheterisation laboratory for immediate intervention.

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