A previously well man in his 70s presented with a 2 month history of progressive dyspnoea, peripheral oedema, and purpuric rash affecting his legs. On examination, he was hypoxic, had ascites, bipedal oedema, and purpura on his legs. Bloods revealed a normocytic anaemia, renal failure, and hypoalbuminaemia. Urine dipstick was ++ protein with a urine protein/creatine ratio of 83 mg/mmol. Chest x-ray showed an elevated right hemidiaphragm. An electrocardiogram (ECG) showed sinus rhythm with first degree atrioventricular (AV) block and low voltage QRS complexes (figure 1). Figure 1 Twelve lead electrocardiogram showing sinus rhythm, right axis deviation, and low voltage complexes in the chest and limb leads. CT of the chest–abdomen showed bilateral pulmonary emboli, ascites, and small kidneys with no focal lesions. The caecal wall was irregularly thickened, suggestive of malignancy or colitis …