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Intravascular volume expansion and ionotropic support should immediately be started if the patient is haemodynamically compromised. Echocardiography-guided pericardiocentesis remains the urgent definitive treatment of choice regardless of the underlying cause. The decision to leave an indwelling catheter after initial complete drainage depends primarily upon the possible aetiology of pericardial effusion. In our patient, absence of pulsus paradoxus/electrical alternans/muffled heart sounds but the presence of diastolic pericardial knock were features suggestive of possible constrictive pericarditis on admission. Within 24?h, the patient's MG132 sudden clinical deterioration and haemodynamical instability with documented two-dimensional echo features suggestive of cardiac tamponade emphasise the importance of understanding the dynamic spectrum of disease from constriction to tamponade. The postpericardiocentesis right heart catheter pressure tracings were suggestive of effusive�Cconstrictive pericarditis. Even though non-steroidal anti-inflammatory drugs are the standard of care for the management of acute pericarditis and effusive�Cconstrictive pericarditis, our patient's renal failure precluded its use in first place. Even though worsening of renal function after starting steroids in scleroderma patients, in the form of scleroderma renal crisis is a well-known phenomenon, there were no clear reports against steroid use in pericarditis in such patients. Although there are some anecdotal reports of rapid clinical deterioration of pericardial disease after starting steroids,4 emphasises the need for more studies in this aspect. We are reporting this case due to rarity, unusual initial presentation, challenges in establishing the final diagnosis and aggressive clinical course. Learning points Cardiac involvement in scleroderma can be direct (myositis, cardiac failure, myocardial fibrosis, conduction system abnormalities, coronary artery disease and pericardial disease) or indirect due to the involvement of other organs (eg, pulmonary hypertension, renal crisis).5 Though myocardial fibrosis and heart block have been considered the most frequent clinical presentation of cardiac involvement, pericardial disease is recently being increasingly reported. Necropsy studies report the prevalence of pericardial disease is in between 33% and 72% of cases, while symptoms from pericarditis occur in only 7�C20% of patients.5 Rapid diagnosis and treatment is indicated in cardiac tamponade. Intravascular volume expansion and inotropic support should immediately be started if the patient is haemodynamically compromised. Echocardiography-guided pericardiocentesis remains the urgent definitive treatment of choice regardless of the underlying cause.