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Circulation, Volume 150, Issue Suppl_1, Page A4145478-A4145478, November 12, 2024. Introduction:Pericarditis is an inflammation of the pericardium, a thin sac-like membrane surrounding the heart, which can progress to life threatening cardiac tamponade. It can be caused by infections (viral, bacterial, fungal, or parasitic), autoimmune conditions, injuries, or underlying medical conditions. Common symptoms include chest pain, fever, shortness of breath, and fatigue. In the case presented, the patient suffered from a severe form of pericarditis caused by a rare infectious etiology, leading to the development of cardiac tamponade.Case Summary:A 29-year-old female with type II diabetes and hypothyroidism presented with a week of shortness of breath, chest pain, lightheadedness, and loss of consciousness. Workup showed WBC (20.6), CRP (283), and ESR (85). Echocardiogram revealed a large pericardial effusion with right ventricular collapse, indicating cardiac tamponade. She underwent pericardiocentesis, draining 400 ml of exudative fluid. Unfortunately, the effusion rapidly re-accumulated, requiring a pericardial window procedure with drainage of fibrinous, loculated fluid over 2 days, improving her symptoms. She was discharged on colchicine and NSAIDs, however she returned 5 days later with recurrent symptoms and fever. The culture of the previous fluid showed Cutibacterium acne. Histopathology of pericardial biopsy revealed fibrinoid pericarditis. She was treated with ceftriaxone, and transitioned to doxycycline for 14 days, along with 14 days of ibuprofen and 3 months of colchicine. At 3-month follow-up, she was asymptomatic with no effusion recurrence.Conclusion::As bacterial pericarditis cases rise, the initial work-up should include investigating bacterial etiology. This raises the question of antibiotic coverage for patients presenting with pericardial effusion until bacterial etiology is excluded and also advocate for elective pericardiocentesis in bacterial effusions without tamponade physiology.