acute tamponade especially with bloody fluid should always require oncological diagnostics of potential neoplastic growth [ 1 , 2 ] . there are only a few reports of acute bloody pericardial tamponade in immunocompetent patients due to viral infection . we present the dramatic course of a female 5-year - old child with pneumonia and symptoms similar to local compression of the pericardium by a tumor - mimicking mass originating from the left lung . a five - year - old child , body weight 23 kg , with acute cardiac tamponade in the course of treated pneumonia , was referred from the local hospital for emergency surgical intervention . the reason for hospitalization was abdominal pain with nausea ; c - reactive protein was in the normal laboratory range ( < 5.0 mg / l ) ; no changes in chest x - ray were present . the patient underwent antibiotic treatment ( amoxicillin + clavulanic acid 3  480 mg i.v . for 6 days , netilmicin 3  40 mg i.v . for 4 days ) , and the imaging diagnostics suggested left lung pneumonia with left inferior lobe atelectasis , which impressed the pericardium in a way similar to a left lung tumor with aggressive local growth . the laboratory investigations were not specific for neoplastic disease or tuberculosis infection , although there were atypical forms in the blood shape . the child was initially referred for chest drainage because of the left pleural effusion ( fig . 1 ) , but the chest drainage did not improve severe hypoxia caused by dyspnea at rest and shortness of breath , despite constant oxygen delivery . after the next 2 days , despite pleural drainage and change of antibiotics ( ceftazidime 2  500 mg i.v . and fluconazole 1  50 mg i.v . ) , the child deteriorated rapidly due to rapid symptoms of heart failure , shortness of breath and fatigue . in the echocardiography performed just before the intervention there was acute tamponade with local impression of the left atrium and the left ventricle , with functional mitral valve regurgitation grade ii ( mvi + + ) , without any congenital defects ( fig . preoperative chest x - ray showing massive pleural fluid preoperative echocardiography showing acute tamponade with local heart impression surgical intervention was performed with the cooperation of a multidisciplinary team ( cardiac surgeon , pediatric surgeon , cardiologist , radiologist , oncologist ) . the bloody effusion of 200 ml was evacuated with dynamic outflow under pressure and the heart was dissected free from the fresh fibrous adhesions . in the direct inspection there was clear evidence of solid extrapericardial impression in the area of the left atrium ; therefore all manipulation in the pericardium was very gentle . the chest tube with active suction was left in the pericardial sac underneath the inferior wall of the heart . the specimens from pericardial tissue and the fluid were harvested for further laboratory and histopathological tests . postoperative computed tomography did not confirm pericardial infiltration and showed no clear evidence of mediastinal tumor ( fig . the condition of the girl improved and after control echocardiography the drainage was removed 24 hours after surgery . there was persistent impression on the left ventricle with pericardial fluid separation inside the pericardium in the field of the left ventricle . only after the surgery was completed were the previous blood cultures found to be negative . pericardial fluid examination revealed bloody liquid with the density of 1.01 g / l ( ph 8 ; protein 53.5 g / l ; glucose 62 mg% ; ldh 1326 u / i ; amylase 36 u / i ) . histopathological examination of pericardium and pericardial fluid revealed no signs of neoplastic growth or atypical cells , with inflammatory reaction signs . the child was transferred back to the referring department of pediatrics for continuation of antibiotics on the 4 postoperative day ( ceftazidime , fluconazole ) . control echocardiography showed no impression over the left ventricle and a small amount of fluid in the area of the left ventricle . the follow - up observation has now reached four years and there have been neither cardiac episodes nor pericardial fluid recurrence . the presented case is unique because of the age of the child and aggressive growth of the pericardial effusion leading to ongoing circulatory and respiratory compromise that suggested neoplastic tumor , but neither imaging studies nor histopathological examinations confirmed disseminative disease . an alternative to the diagnosis of tumor was acute viral infection with an undefined microorganism , with rapid disease course as well as pleural and pericardial fluids . most of them are patients with circulatory insufficiency due to heart failure with mediastinal neoplasms and local impression of the heart . in our case the decision to perform an emergency ministernotomy was undertaken in the face of a circulatory insufficiency with awareness of a lack of final diagnosis in a patient in an emergency setting . the primary clinical diagnosis , confirmed by imaging , did not exclude a heart tumor , pulmonary neoplasm , or cardiomyopathy . we performed the procedure with the very best oncologic vigilance in emergency settings , despite the lack of a final diagnosis . the presented minimally invasive approach proves the safe possibility of mediastinal exploration with effective fluid evacuation in emergency , which is our commonly used , and recommended in many centers , ministernotomy of choice . this method , although commonly reported as the second step after initial pericardial puncture , enables pericardial inspection , dissection of pericardial adhesions , and macroscopic evaluation of the heart , while being related to lower risk of complications . emergency tamponade drainage was necessary to save and stabilize the patient , who was subjected to continued antibiotic chemotherapy and further diagnostics . the clinical image observed while on perioperative treatment was unclear , more similar to an intrathoracic tumor than pneumonia with left lung atelectatic lobe . the presented clinical course can be a challenge for diagnostics and therapy that needs meticulous clinical examinations to prevent the oversight of potentially hazardous symptoms and terminal diseases , despite oncologic vigilance . the good early result enabled early extubation and simultaneous to planned anesthesia weaning of the patient from mechanical ventilation , which corresponds to contemporary literature reports [ 16 ] . the procedure was the turning point for continuation of therapy , as well as for precise histopathological diagnosis and subsequent modification of further examinations and strategy of care . the presented case report emphasizes the role of a multidisciplinary approach in critically ill children with pericardial tamponade . although the rapid disease course was due to viral infection , we could not exclude ah1n1 etiology of infection ; no such test was done in our department before the ah1n1 pandemic in 2009 [ 7 , 8 ] .
we present the dramatic course of a female 5-year - old child with pneumonia and symptoms similar to local compression of the pericardium by a tumorous mass originating from the left lung . 
 the child was treated with antibiotics for pneumonia with bilateral pleural effusions that required chest drainage . on the 10th day of therapy 
 there was sudden anemia observed with the echocardiographic finding of acute cardiac tamponade . 
 the child was referred for emergency life - saving surgical intervention . 
 the chest was opened via a minimally invasive mini - incision in the area of the xiphoid process and bloody tension pericardial effusion was evacuated . 
 the laboratory and histopathology investigations were not specific for neoplastic disease or tuberculosis infection . in the further observation 
 the girl recovered and was discharged home two weeks after tamponade drainage . 
 fortunately our initial suspicion of neoplastic disease was not proved ; nevertheless we would like to emphasize the need for oncologic vigilance in similar cases .