A 79-year-old man developed cardiac decompensation due to a tacrolimus-induced hemodynamically significant pericardial effusion that was relieved by subxiphoid pericardial drainage. Because of clinical deterioration twelve days after pericardiocentesis, a computed tomography (CT) scan of the thorax and abdomen was performed. The CT scan (Figure 1) revealed a large ventrally located pneumopericardium with a maximum width of 5.5 cm as well as displacement and compression of cardiac structures and the left upper lobe of the lung. In addition, pneumoperitoneum with large amounts of free air along the ventral abdominal wall was apparent.

FIGURE 1
figure 1

Computed tomography scan showing pneumopericardium (*), ventrally located pneumopericardium (*), displacement and compression of cardiac structures (#) and the left upper lobe of the lung (+), and pneumoperitoneum (§)

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Paramediastinal minithoracotomy showed tension pneumopericardium. Laparotomy revealed a small serosal lesion of the small intestine and a perforation of the transverse colon, possibly caused by the pericardial puncture. After the therapeutic procedures, the patient recovered, gave written informed consent for publication of the complication, and was discharged from the intensive care unit after six days.

A combined pneumopericardium and pneumoperitoneum of such a size represents a rare complication of pericardiocentesis. In the case of clinical deterioration, even with a significant time delay after pericardiocentesis, it is necessary to consider this rare diagnosis. Although it is often self-limiting, fulminant and life-threatening courses also occur. In these cases, immediate decompression via re-pericardiocentesis or pericardiotomy is required.