A 48-year-old male patient presented to the cardiology outpatient department with complaints of shortness of breath for the past one month. The onset was insidious and gradually progressive, on ordinary activity to start with and on less than ordinary activity for the past one week. He was diagnosed as a case of CML five years prior to current admission and was on treatment with Imatinib mesylate for three years. However, due to the development of resistance and poor treatment response, he was started on Dasatinib 100 mg once daily two years back.On general physical examination, patient was afebrile and was found to have cold extremities, tachycardia (110/min), tachypnoea (30 breaths/min) and hypotension (BP-90/60 mm Hg). He had pulsus paradoxus and jugular venous pressure was raised with prominent X descent, absent Y descent and showing normal decrease on inspiration. On systemic examination his apical impulse was poorly localised and on auscultation, his heart sounds were muffled. Examination of chest revealed decreased bilateral air entry, but more decreased on the right side.Chest X-ray was suggestive of bilateral pleural effusion, on the right side more than left, with cardiomegaly. Electrocardiography showed electric alternans [Table/ Fig-1], while two dimensional echocardiography showed massive pericardial effusion all around the heart, with collapse of right atrium and right ventricle occuring early during diastole [Table/ Fig-2]. Inferior vena cava was dilated and showed no size variation with respiration. An exaggerated respiratory variation on Doppler velocity recordings was seen in the trans-valvular flow with inspiratory increases on the right and decreases on the left.Pericardiocentesis was done and 600 ml of pericardial fluid was removed. Pericardial fluid was subsequently sent for analysis. Patient symptoms were relieved following pericardiocentesis. However, repeat pericardial collection was seen on repeat echocardiogram the next day. Repeat pericardiocentesis of 600 ml was done.Pericardial fluid analysis showed exudative nature of the fluid with high protein (6.5 g/dl), low glucose content (36 mg/dl) and high LDH level (304 U/L); while the ADA level was low at only 16 U/L. Pathological analysis showed 190 cells with lymphocytes being the dominant cell type (86%).No malignant cells were seen on cytological analysis with benign mesothelial cells in a background of neutrophils and lymphocytes dominating the field. Pericardial fluid showed no microbial growth on culture even after 72 hours. Fluid was sent for PCR for Mycobacterium tuberculosis, which turned out to be negative.Post pericardiocentesis contrast enhanced CT scan of the chest showed mild pericardial effusion and bilateral pleural effusion. Dasatinib was stopped and patient was restarted on imatinib mesylate. There was no recurrence of serositis on imatinib and

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