The CXR shows globular enlargement of the cardiac shadow. The lungs and pleural spaces are clear. The differentials include pericardial effusion, cardiac chamber enlargement or cardiomyopathy. In this case, as the patient had a normal CXR 5 months prior, the most likely diagnosis is a pericardial effusion. A globular appearance (Money bag appearance) to the cardiac outline has been described with pericardial effusions, but the most useful sign is a rapid change in hea size or shape with little or no evidence of pulmonary venous congestion. Diagnosis is usually confirmed by echocardiography.