An 84-year-old man with a known history of hypertension, COPD, diabetes, Parkinsonism, and old CVA (putamen infarction)* was noted to be delirious after five days of having reduced appetite and general weakness. A brain CT done at the neurology clinic revealed no significant abnormality. Later, he complained of chest pain and developed intermittent low-grade fever alongside cold sweats but no cough, dysuria, diarrhea, or SOB. At the Emergency Department, he appeared chronically ill. BP measured 117/59 mmHg and BT/PR/RR 35.1C, 100/min (irregular), and 17/min, respectively. Despite basilar crackles in both lungs, there were no signs of heart failure (HF). ECG showed AF with an average ventricular rate of 117/min. Hb was 12.2 gm%, WBC 6890, Plt 144k, SGOT 47 U/L, SGPT 34 U/L, Na 134 mEq/L, K 3.4 mEq/L, BUN 33.7 mg/dL, Cr 1.5 mg/dL, CKMB 4.4 ng/mL, troponin I < 0.05 ng/mL and CRP 9.31 (N <3) mg/dL. Chest X-rays revealed possible RML, LLL pneumonia, and slight cardiomegaly with LA enlargement. After blood samples were drawn for culture, the care team started IV fluid and antibiotics with cefazoline and metronidazole. The following day, the patient became highly uncomfortable; the skin was cold and clammy. BP measured 83/53 mmHg and BT/PR/RR 38.1ºC, 80/min, and 20/min, respectively. ECG exhibited sinus rhythm at 79/min; there was ST-segment (concave) elevation in limb and precordial leads (II, III, aVF, V4-V6), with J point depression in aVR suggesting epicardial injury (e.g., acute pericarditis). Repeated Hb was 11.3 gm%, WBC 13860 (Band 15%) Plt 93k, CKMB 3.7 ng/mL, troponin I < 0.05 ng/mL, lactate 6.21 (N 0. 5 to 2. 2) mmol/L, procalcitonin** 20.54 (N <0.1 ) ng/mL. The care team quickly infused normal saline 1500ml and raised BP to 120/77mmHg with levophede drip (6.5mcg/min). Under the suspicion of septic shock vs. “cardiac tamponade” due to “aortic dissection,” the care team obtained a chest CT scan with contrast. It revealed no aortic dissection, but there was cardiomegaly with pericardial effusion. Pericardiocentesis removed 350ml yellow turbid viscous liquid (pus) with a Sp.gr of 1.037, protein-positive, containing RBC 1520 /cumm and WBC 8560 (neutrophil 99 %) /cumm. The hemodynamics became stable even after tapering off the levophed drip. The specialist felt the additional finding of pericholecystic fluid collection on the CT scan was a benign condition. Subsequent blood cultures grew positive for salmonella group D, as did the pericardial fluid. A surgical pericardiotomy*** was then performed to prevent reaccumulating pericardial effusion. To treat Salmonella sepsis, the care team used ceftriaxone, a 3rd generation cephalosporin, based on sensitivity testing to suppress salmonella sepsis with purulent pericarditis. Lastly, echocardiography showed preserved LV contractility (EF:65%), small residual pericardial effusion, and no abnormal regional wall motion. In retrospect, the only significant history likely to be the source of salmonella infection was that he had “sushi” (Japanese raw fish meal) for supper a few days before he became sick.