We present the case of a 66 year old man with a background of nephrectomy for renal cell carcinoma, who presented with shortness of breath and low oxygen saturations. Following a raised D-dimer he was started on therapeutic dose low molecular weight heparin for a presumed pulmonary embolism. Shortly after this, he acutely desaturated and was found to be in extremis. A repeat chest radiograph demonstrated a white out of his right lung. He was managed on the Intensive Care Unit and a chest drain was inserted and drained several litres of frank bloods, confirming the diagnosis of haemothorax. Pleural cytology did not demonstrate any malignant cells. A contrast computed tomographic scan of his chest revealed lobulated right-sided pleural thickening of 18mm, which was suspicious for metastasis. Further discussion at Urology MDT confirmed pleural metastasis from renal cell carcinoma.

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