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Abstract Background Pneumopericardium is a rare complication in patients with bacterial necrotizing pneumonia and proven to be lethal with a high incidence of mortality due to cardiopulmonary failure. Case presentation This is a rare case of broncho-pericardial fistula in a 21 year old, who was a known case of T-cell acute lymphoblastic leukemia status post-chemotherapy, presented with relapse of acute lymphoblastic leukemia. He was evaluated for febrile neutropenia. Further investigation showed features of necrotizing pneumonia and follow-up chest X-ray during the hospital stay showed evidence of pneumopericardium. To localize the cause, computed tomography chest was performed, further confirming the etiology of bronchopericardial fistula. Conclusions Our case illustrates broncho-pericardial fistula as a rare complication of necrotizing pneumonia and the utility of multimodality imaging in its diagnosis and determination of tension pneumopericardium.