Sir,I read the article on “Unusual presentation of pericardial effusion” by Saseedharan et al., with interest.[1] I have to commend the authors for highlighting well certain salient features of pericardial effusion symptomatology and clinical aspects of cough syncope. But there are some unexplained factors that had been left unattended in the case report.The authors do mention that the predominant feature of this particular case presentation is cough syncope, and they also do mention that this is possibly related to raised intrathoracic pressure. But what is lacking is the clear association with a prominent right hilar shadowing, a cytology positive for metastatic non-small cell carcinoma, and moderate effusions at both pleural cavities along with this pericardial effusion. Even the right supraclavicular node showed a positive cytology for confirming a spreading disease, possibly from a focus in the lung. Any of these could also lead to elevation of intrathoracic pressure, however, transiently, and present with cough syncope. Also noteworthy are the findings on CT scan, showing features of concentric thickening of bronchial tree in the right lower lobe.Even if a metastatic lesion is found during a process of treatment of symptom-inciting condition, it is mandatory that one search for the primary disease to stage the lesion correctly, and ascertain the prognosis along with the treatment pathway. With the moderate effusion as shown by the imaging, it would be difficult to establish this as the actual cause of cough syncope rather than the whole complex of lung disease or pleural effusions. Absence of cardiac tamponade should also alert one to other explanations of the symptoms, and to work up the case in more detail than shown here.