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A 71-year-old woman, with a history of light-chain amyloidosis, presented with a sudden onset dyspnoea. Echocardiography showed a large pericardial effusion with compression of the right atrium and the right ventricle. Right heart catheterisation demonstrated equalisation of her diastolic pressures consistent with cardiac tamponade. Pericardiocentesis revealed a haemmorrhagic exudative effusion with no evidence of malignancy. Bone marrow biopsy and other investigations showed no evidence of multiple myeloma. Her effusion recurred 2 weeks later and repeat pericardiocentesis demonstrated similar findings. She was started on chemotherapy with no further recurrence of pericardial effusion. The patient was unable to tolerate chemotherapy and died 1 year after initial presentation. This case represents a rare manifestation of cardiac amyloidosis and explores the reported aetiologies for cardiac tamponade in the setting of light-chain amyloidosis. Acute and definitive treatments are also discussed.

A young man from California presented with acute onset of cough, fevers, night sweats and pruritus with dark urine. Laboratory studies were notable for moderate transaminitis with elevated bilirubin and eosinophilia. Hepatitis panel, HIV screen and heterophile antibodies were negative. CT scan showed multiple bilateral focal opacities with hilar and mediastinal lymphadenopathy with no ductal dilation or gallbladder stones. The patient had positive coccidioidomycosis serologies and he was started on fluconazole with resolution of symptoms and improvement in transaminitis over the next month. This article highlights a rare manifestation of disseminated coccidioidomycosis with symptomatic hepatitis. Although an increasingly prevalent infection found in southwest USA, dissemination is rare in immunocompetent hosts. Postmortem studies suggest hepatic involvement is common in disseminated infection. However symptomatic hepatitis is rare, with only three cases of symptomatic hepatitis found in the literature.