A 49-year-old man was transferred to our tertiary centre with pyopneumopericardium diagnosed on computed tomography (CT) of the chest. The patient presented with a 1 day history of sharp central pleuritic chest pain and bilateral sharp scapular pain associated with fevers, vomiting, and diaphoresis. The pain was improved by leaning forward and worse when lying flat. Examination revealed a regular heart rate of 97 beats per minute, blood pressure of 133/93 mmHg, respiratory rate of 22 breaths per minute, and oxygen saturations of 95% on 3 L of oxygen via nasal cannulae. Temperature was 37.3°. A unique continuous murmur was audible throughout the praecordium associated with a pericardial rub and succussion splash (see Video 1) which the authors have named the ‘Lee-Ramkumar-Dundon’ murmur. The patient’s past medical history was significant for obesity (body mass index of 34 kg/m2), with a previous uncomplicated Roux-en-Y gastric bypass surgery performed in 2013, psoriatic arthritis managed with leflunomide 10 mg daily, type 2 diabetes mellitus managed with metformin, and hypercholesterolaemia well controlled on simvastatin 40 mg daily. He was a non-smoker with no history of ischaemic heart disease or malignancy. Admission electrocardiogram (ECG) demonstrated widespread PR interval depression, with reciprocal aVR PR interval elevation, 1 mm horizontal ST-segment elevation in leads I, II, aVL and V6, and isolated T-wave inversion in lead III (see ). Blood tests revealed a haemoglobin of 166 g/L (reference range 135–175 g/L), white cell count of 21 200 cells/µL (reference range 4500–11 000 cells/µL), platelets of 223 000/µL (reference range 150 000–450 000/µL), and C-reactive protein of 312 mg/L (reference range 0–8 mg/L). A single troponin I performed 9 h after onset of chest pain was 0.02 µg/L (reference range 0.00–0.08 µg/L). The patient was not bacteraemic. Chest X-ray demonstrated a heterogeneous gas lucency surrounding the cardiac silhouette (see ). Computed tomography of the chest and the upper abdomen demonstrated a large volume pneumopericardium with air fluid levels and gas locules associated with a direct communicative tract with the gastrojejunostomy (see ). The purulent pericardial drain fluid grew methicillin-sensitive Staphylococcus aureus, Streptococcus salivarius, Streptococcus parasanguinis, Escherichia coli, and Candida albicans in culture. A transthoracic echocardiogram performed postoperatively demonstrated normal left ventricular size and normal left ventricular ejection fraction of 60%. There was echogenic material in the pericardial space associated with ventricular interdependence and annulus reversus. The patient was taken urgently to the operating theatre where a chronic ulcer perforation involving the diaphragm and pericardium was demonstrated. This was repaired with an omental patch. The small pleural and pericardial effusions were drained by left thoracotomy. An omental repair drain, and an underwater joint pleural and pericardial drain were placed. Postoperatively, the patient was commenced on culture-guided intravenous ceftriaxone, clindamycin, and fluconazole as per the infectious diseases team. After 1 week of bowel rest with parenteral nutrition to allow adequate healing of the gastro-jejunostomy repair site, a gastrograffin follow through the study was performed, demonstrating no contrast extravasation. Subsequently, the omental drain tube was removed and the patient’s diet was slowly upgraded to a puree diet on postoperative day 14. The patient’s postoperative course was complicated by persistent purulent output from the joint pleural and pericardial drain as well as re-accumulation of a loculated left-sided pleural effusion. This was managed with a repeat pericardial washout and intercostal catheter insertion on postoperative days 31 and 44, respectively. The patient was discharged home after a 49 days hospital admission with two further weeks of oral amoxicillin/clavulanic acid and with pantoprazole 40 mg daily for ulcer prophylaxis. The patient attended a 2 months of follow-up with the upper gastrointestinal surgeons and were clinically stable with no recurrent chest pain or infective symptoms. A repeat CT chest abdomen and pelvis 10 months post-admission demonstrated no intra-abdominal collection and a small volume pericardial fluid which had reduced in size since the patient’s admission. A timeline of the patient’s hospital stay is provided in the Timeline section.