A middle aged woman, diagnosed case of decompensated cirrhosis of liver (Child Pugh class C, Model for end stage liver disease score 24), secondary to chronic hepatitis C infection presented to our emergency department with severe breathlessness and associated bloating and swelling of face, neck, upper chest and upper arms since one day. Five days prior, elsewhere, she had undergone evaluation for cough, pleuritic chest pain and right sided heaviness over the thorax, following which, she was diagnosed as having localized right sided pleural effusion for which she underwent pig tail intercostals chest drain placement ( Figure 1A). Subsequently, pleural fluid reports were suggestive of low protein and high serum to pleural fluid albumin gradient (SPAG) with leukocyte count of 500 cells, which was lymphocytic predominant. During further hospital stay, new onset dull aching chest pain, prompted the treating physician to manipulate the chest drain as serial chest X rays were suggestive of drain migration. Thirty six hours afterwards the patient developed severe progressive breathlessness with rigid chest wall leading to respiratory embarrassment. A computed tomography revealed extensive subcutaneous emphysema (SCE) with pneumo-mediastinum and pneumothorax. (Figure 1B Subcutaenous large bore needle drain placements dramatically reduced the emphysema, but the patient developed multiple skin and soft tissue infections, nosocomial pneumonia and secondary bacterial pleuritis in hospital eventually leading to death. Pleural effusion (PE)