Figure 3: Echocardiographic apical four-chamber views demonstrating pneumopericardium. (a) There was a large (20 mm) circumferential layer (white arrows) within the pericardial space, with its heterogenous nature suggestive of possibly purulent pericardial fluid. Marked thickening of the pericardium (5 mm) can also be appreciated in this view (red arrow). (b) Slight angulation of the probe to focus on the anterior pericardial space (anterior to the right ventricle) revealed the presence of microbubbles (yellow arrow) representing air freely moving within the pericardial sac.