A 59-year-old male with an unremarkable past medical history presented with worsening dyspnea and a history of chest tightness for 2 weeks. He had arthritis of multiple hand and foot joints bilaterally. Muffled heart sounds and pulsus paradoxus of 15 mm Hg were noted on examination. Laboratory findings were remarkable for anemia, with a hemoglobin level of 8.9 g/dL (normal, 13.5 to 17 g/dL), proteinuria level of 0.9 g/d, positive antinuclear antibody level of 906 U/mL (normal, 0 to 99 U/mL),

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... positive anti-DNA (DS and SS) antibodies. A chest x-ray showed a large cardiac silhouette. A 2-dimensional transthoracic echocardiogram revealed a large circumferential pericardial effusion (Figure 1 , asterisks), with remarkable intrapericardial adhesions (fibrin strands) that had a worm-like appearance and were partially attached and floating between the visceral and parietal pericardium (Figure 1 and Data Supplement Movie). Pericardiocentesis was performed to drain 1700 mL of bloody fluid. Posteroanterior chest x-ray (Figure 2 ) showed the heart before (left) and after (right) pericardiocentesis. An ECG (Figure 3 ) before (upper) and after (lower) pericardiocentesis is shown. The final diagnosis of systemic lupus erythematosus presenting with cardiac tamponade was made. Disclosures None. The online-only Data Supplement, which contains a movie, can be found at http://circ.ahajournals.org/cgi/content/full/116/11/e342/DC1.