Presentation
"CLL"
![](https://prod-images-static.radiopaedia.org/images/315813/3f54475ca332bffc26a4d422889e63_thumb.jpg)
![](https://prod-images-static.radiopaedia.org/images/315819/dc850348de3c17dd6fcb005c01fa34_thumb.jpg)
![](https://prod-images-static.radiopaedia.org/images/315813/3f54475ca332bffc26a4d422889e63_big_gallery.jpg)
Enlarged cardiac silhouette with globular shape, without evidence of pulmonary venous congestion. Lungs and pleural spaces are clear.
![](https://prod-images-static.radiopaedia.org/images/315850/a99533f327447da38da4415a10e4f3_big_gallery.jpg)
Pericardial effusion is evident (increased fluid-density around the heart) and this is the cause of the enlarged cardiac silhouette on chest x-ray. Numerous axillary and mediastinal lymph nodes.
![](https://prod-images-static.radiopaedia.org/images/1436764/5bbea01430437883505ebc997ef7c8_thumb.jpeg)
![](https://prod-images-static.radiopaedia.org/images/1436771/c265f353d7bc6ae0e4e286546c4e7a_thumb.jpeg)
![](https://prod-images-static.radiopaedia.org/images/1436757/30700792d698c6f83326ea57c065d3_thumb.jpeg)
![](https://prod-images-static.radiopaedia.org/images/1436764/5bbea01430437883505ebc997ef7c8_big_gallery.jpeg)
Pericardial fluid (yellow *) outlined by paracardial fat (blue arrows) and epicardial fat (orange arrows), giving a three layered appearance, known as an Oreo cookie sign.
Oreo Cakesters cookies, made by Nabisco. Photo by Evan-Amos. Original file: http://commons.wikimedia.org/wiki/File:Oreo-Cakesters.jpg
Case Discussion
Pericardial effusion in a woman with chronic lymphocytic leukemia (biopsy-proven). Chest x-rays demonstrate a globular shaped heart, without evidence of pulmonary venous congestion.
CT confirms the presence of a pericardial effusion as well as numerous axillary and mediastinal lymph nodes.