The 56-year-old man came to the Emergency Department complaining of progressive dyspnea and chest tightness with a nonproductive cough for six months despite a few weeks of antibiotic treatment. He also described having low-grade fever and night sweats but no diarrhea, dysuria, PND, or orthopnea. Past medical history was significant for diabetes mellitus (DM) and hypertension, for which he had been taking anti-DM and antihypertensive medications for over ten years. He appeared chronically ill and was in moderate respiratory distress. BT/PR/RR was 36.7 ºC/108/min/19/min, and BP measured 134/86 mmHg. JVD was 10 cm H2O, and the liver was 3fb palpable below the right costal margin. PMI was not visible, heart sounds were distant, but no murmurs were audible. ECG showed diffuse low voltage and sinus tachycardia at 103/min with T wave inversion in leads I, II, aVL, and V3-V6. Chest X-ray exhibited a marked increase in the silhouette, suggesting cardiomegaly, a small right pleural effusion, and hepatomegaly. Pertinent laboratory data included Hb 10.4 g/dL, HCT 30.3 %, WBC 9990 (Neutrophil 76.6 %), CRP 4.5 mg/dL, Glu 204 mg/dL, Plt 439 K/ul, BUN 17 mg/dL, Cr 1.03 mg/dL, Na 136 mEq/L, K. 3.6 mEq/L, SGOT 61 U/L, GPT 121 U/L, GGT 58 U/L, TBil 1.82 mg/dl, ALP 106 U/L, INR 1.26, PT 13.5 sec, aPTT 30.4 sec, troponin I 0.02 ng/ml, CKMB 0.02 ng/ml. Subsequent echocardiography revealed significant pericardial effusion. Abdominal echo revealed fatty liver, a hepatic tumor, likely hemangioma, and gallbladder sludge. The CT scan confirmed massive pericardial effusion and right-side pleural effusion as well; there was no tumor or lymphadenopathy. Accordingly, the care team did pericardiocentesis, removed 533 ml of reddish fluid, and inserted a pigtail for drainage. The pericardial fluid appeared exudate containing protein 4.7 gm/dL (serum protein 5.6g/dl) and LDH 1393 U/L (serum LDH 360 U/L) without identifiable organisms under the microscope. The pigtail drained out 70-200 ml of pericardial fluid daily, while daily care documented intermittent low-grade fever (37.8-38.8 ºC). Following consultation with the cardiovascular specialist, a surgeon performed a partial pericardiectomy. The pericardial biopsy revealed granulomatous inflammation with caseous necrosis and was positive for the acid-fast bacillus (AFB) stain, tuberculosis polymerase chain reaction (PCR), and adenosine deaminase (ADA) (+)*. Under the diagnosis of TB pericarditis, The care team added IV steroid (solu-medrol), along with a combination anti-TB chemotherapy (Rifater/Rifinah)** aiming at further reducing the inflammation of the pericardium and improving the survival rate (not proven effective strategy). They also added rapamycin to co-trimoxazole for status post pericardiectomy and possible secondary lung infection. Three weeks later, his liver dysfunction resolved, as TBil, ALK, GOT, GPT, and GGT all returned to normal ranges, and the patient’s condition significantly improved.