A 79 year-old female presented after a syncopal episode on a background of 12 hours of lethargy, dry cough and severe left shoulder pain. A liver transplant was performed 20 years ago for primary biliary cirrhosis with a daily immunosuppressive regimen of Prednisolone, Cyclosporine and Azathioprine. Further history included hypertension and osteoarthritis. On physical examination the patient was hypotensive and required high flow oxygen to maintain oxygen saturations above 95%. General clinical examination was unremarkable except for a delayed response to verbal commands. Laboratory investigations revealed an elevated white cell count of 16.5×10 9/L and reduced glomerular filtration rate of 57 ml/min/1.73m 2, otherwise all other values were within normal limits. Contrast enhanced computed tomography (CT) of the chest and abdomen revealed three penetrating aortic ulcers of varying size along the ascending and descending aorta ( Figure 1, Figure 2, Figure 3) complicated by type A dissection and haemopericardium along the central bronchovascular structures with no evidence of dissection into the pleural space. Transthoracic echocardiography showed a dissection flap as well as a large pericardial effusion and right ventricular tamponade. The left ventricle was compressed with normal systolic function. Due to the patient's chronic immunosuppression and general frailty surgical intervention was not deemed suitable thus supportive therapy and comfort measures were instituted. The patient died six days later.