The globular heart stands out on this rotated and under-inspired frontal x- ray; a bedside echocardiogram revealed a very large pericardial effusion. The patient underwent emergency pericardiocentesis and was diagnosed with a malignant pericardial effusion.

The globular appearance of the heart in pericardial effusion is due to an increase in the transverse diameter but no increase in vertical height. This results in straightening of the superior mediastinal borders giving rise to globular or water bottle shape to the heart.

Reference: www.ajronline.org