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Malignant tension hydrothorax is rare. Here we present a malignant tension hydrothorax secondary to small cell lung cancer (SCLC). To our knowledge, this is the first report of this entity. Briefly, a 53‐year‐old male smoker presented in acute distress after months of fatigue, shortness of breath, and weight loss. On examination his heart rate was 122, respiratory rate 31, blood pressure 102/60, oxygen saturation 92%, and he had tracheal deviation to the left with absent breath sounds on the right. Work‐up revealed hyponatraemia and a large pleural effusion causing tracheal deviation, mediastinal shift and compression of abdominal contents. There were associated masses in the right lung upper lobe and tail of the pancreas. Urgent, interval drainage of the effusion over several hours with tube thoracostomy relieved his symptoms while also avoiding life‐threatening re‐expansion pulmonary oedema. Subsequent thoracoscopic pleural biopsies revealed extensive SCLC. He was advised to begin urgent chemotherapy.