A challenging case of constrictive pericarditis

We report the case of a healthy 35-year-old male who was seen by his primary care physician with complaints of general fatigue, shortness of breath, night sweats, and abdominal bloating which had started several weeks prior to his visit. A CT scan of the abdomen demonstrated the presence of gall stones. He was subsequently seen by the surgeons and, shortly thereafter, underwent laparoscopic cholecystectomy for suspected cholecystitis. Two weeks after the procedure he reported no significant change in clinical symptoms. A cardiology consultation was subsequently requested at which time his physical examination revealed a BP of 120/80 mmHg, (no pulsus paradoxus), pulse 80 beats/min, elevated jugular venous pressure, and a positive Kussmaul’s sign. Auscultation of the heart revealed a regular rate and rhythm with no murmurs or gallops. A ‘pericardial knock’ was audible. There was no evidence of ascites on abdominal examination and no peripheral lower extremity oedema. The ECG showed sinus rhythm with a ventricular rate of 76 beats/min. No ST abnormalities were seen. Chest X-ray showed a normal cardiac silhouette with no evidence of congestion. He underwent a transthoracic echocardiogram (TTE) which demonstrated a mildly thickened pericardium, small pericardial effusion, a ‘septal bounce’, significant respiratory variation of mitral inflow velocities, and a dilated inferior vena cava and hepatic veins (Fig. 1). The constellation of clinical and echocardiographic findings was more suggestive of constrictive pericarditis. Right heart catheterisation was, therefore, not considered necessary. A CT scan of the chest confirmed the mildly thickened pericardium, small pericardial effusion, and a dilated inferior vena cava.

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