60 year old male with a history of homelessness, latent tuberculosis, and methamphetamine abuse. The patient was admitted to the hospital for shortness of breath and leg edema. A urine drug test on admission was positive for methamphetamine.

Chest radiograph (right) shows an enlarged cardiac silhouette, for which a differential of cardiomegaly or pericardial effusion was provided. Subsequent echocardiogram confirmed this was cardiomegaly with a low ejection fraction. The pulmonary vascular markings on the chest x-ray are also prominent, compatible with congestion from heart failure. The patient has a normal past chest radiograph (left) that provides an easy comparison for these findings.