were white blood cell counts 9,300/μL, neutrophil 8,810/ μL, lymphocyte 90/μL, hemoglobin 7.5 g/dL, platelet counts 136,000/μL, blood urea nitrogen 67.6 mg/dL, crea- tinine 3.57 mg/dL, and C-reactive protein 7.83 mg/dL. Chest X-ray showed clear lung fields. Blood, urine, spu- tum, and stool culture were all negative. Chest computed tomography showed minimal multifocal patchy peribron- chialitis. He received intravenous piperacillin-tazobactam 9 g per day for possible pneumonia. Echocardiography showed minimal amount of pericardial effusion and elec- trocardiogram showed normal sinus rhythm. Renal Doppler showed no demonstrable abnormality in the transplanted kidney. Despite the use of antibiotics, he remained unwell with chest discomfort and chest pain except fever subsided. After 2 days of admission, chest pain got worsen and blood pressure fall to 90/60 mmHg. Electrocardiogram showed ST elevation in lead I, II and V4 to V6 and ST de- pression in aVR. Cardiac profiles showed Troponin I 0.018 ng/mL (normal range, 0 to 0.78 ng/mL), creatine kin- ase-MB 0.51 ng/mL (normal range, 0 to 5 ng/mL), N-termi- nal prohormone of brain natriuretic peptide 4,349 pg/mL (normal range, 0 to 88 pg/mL). Nitroglycerin test was positive. The chest pain was controlled by morphine. Coronary angiography was taken to rule out myocardial infarction. Coronary angiography showed no significant coronary artery disease and no collapsed chamber. Under intensive care unit monitoring, his blood pres- sure gradually decreased and reached 60/40 mmHg. Emergency transthoracic echocardiography was perfor- med. The parasternal long-axis and apical four-chamber views showed large pericardial effusion which was sur- rounding heart, reaching 3 to 4 cm thickness in some parts, and causing marked compression to the whole heart (Fig. 1). Pericardiocentesis was performed immediately and nearly 1 L of serous fluid was aspirated from the patient. Samples from the pericardial fluid were prepared for bio- chemical, microbiologic, and pathologic examinations. After pericardiocentesis, artery blood pressure began to increase, and chest pain subsided. The results of peri- cardial fluid were white blood cells＞1,000/μL (neutrophil 90% and lymphocyte 1%), glucose 249 mg/dL, protein 3,890 mg/dL, lactate dehydrogenase 2,221 U/L, and albu- thesurgery.or.kr Cardiac tamponade caused by tuberculosis pericarditis Fig. 1. Parasternal long-axis view showing large pericardial effusion (arrow) and right ventricle collapse (asterisk). The D-shape of left ventricle was detected in diastole which was affected by respiratory variation. min 2,020 mg/dL. Biochemical analysis showed exudative pericardial effusion. Acid-fast staining of pericardial fluid was positive, but the results for other sites such as sputum and urine were negative. Mycobacterium tuberculosis was isolated from pericardial fluid. Tacrolimus and mycophe- nolic mofetil except steroids were discontinued. He re- ceive steroid (60 mg) for the treatment of acute pericarditis. Antituberculosis treatment with isoniazid 300 mg qd, rifampin 600 mg qd, ethamubutol 1,200 mg qd, and pyrazinadmide 1,500 mg qd was initiated. Symptoms such as chest pain and fever were subsided after the ini- tiation of antituberculosis treatment. After 7 days, tacroli- mus and mycophenolate mofetil were added for immunosuppression. The drug level of cyclosporine sus- tained low due to the drug interaction with rifampin, so we changed the drug to levofloxin 250 mg. The patient’s general condition improved and creatinine decreased to 2.15 mg/dL. He was discharged from the hospital. During the follow-up period of 3 months, no sign of deterioration was observed and echocardiographic finding showed minimal pericardial effusion without hemodynamic instability. DISCUSSION Tuberculosis pericarditis is detected in 1 to 2% of all acute pericarditis cases. Cardiac tamponade is the main S41