This case involves a 58-year-old female presenting with bilateral foot swelling for 8 weeks, central chest pain for 4 weeks, and heart palpitations for 4 weeks. Her history and examination are consistent with constrictive pericarditis. Key findings include elevated JVP, muffled heart sounds, and signs of chronic liver disease. Constrictive pericarditis occurs when chronic inflammation leads to a thickened, fibrotic pericardium that restricts cardiac filling. Common causes are tuberculosis, other infections, radiation, and idiopathic. Definitive treatment is pericardiectomy, while medical management may be considered for less severe cases.

1. CASE 1
Internal Medicine
Natangwe Shimhanda
11 May 2018

2. PRESENTATION OUTLINE
 Case
 History
 Physical Examination
 Investigations
 Case Discussion
 References

3. HISTORY
 Ms. XX
 58 years old; female; RVD reactive on
TDF/FTC/EFV (suppressed virologically)
 Presented to IHO MOPD with a history of:
 Intermittent Bilateral feet swelling for 8 weeks
 Non radiating central chest pain for 4 weeks
 Heart palpitations for 4 weeks

4.  No cough; no shortness of breath; no orthopnea; no PND; has
easy fatigability; no night sweats; no significant loss of weight
 Seen about 9 weeks ago at Opuwo district hospital with acute
confusion; bilateral pedal oedema; ascites
 Assessed with heart failure and was discharged on lasix and
aldactone
Strong history of alcohol use; not known with any cardiac
conditions

5.  Past Medical History:
 RVD + on TDF/FTC/EFV; CTx/MVTs
(changed in 2016 from the old regimen AZT/3TC/NVP)
 No other comorbidities
 Completed INH therapy in 2015
 Treated for PTB in the 1980s

6. EXAMINATION
 She looked wasted; Was alert and comfortable on
room air
 Vitals: bp: 108/77mmHg; pulse: 76bpm; temp:
36.2; SPO2: 98% on room Air; BMI – 17kgm^2
 Bilateral mild pitting pretibial oedema; stigmata of
Chronic liver disease: loss of axillary hair;
leuconychia

7.  CVS: Raised JVP, weak regular peripheral pulses; s1 and
s2 were audible and not muffled, no murmurs, no
heaves, apex beat was in the 5th I/C mid clav line
 Resp: normal vesicular breath sounds, no added sounds

8. INVESTIGATIONS

9. BLOOD RESULTS
 Full Blood count:
 WCC: 4.12
 HB: 11.30
 Platelets: 256
 Urea & Electrolytes:
 K:5
 Na: 141
 U: 4.2
 Cr: 59
 TFTs:
 TSH: 2.15
 Free T4: 9.05
Differential count:
Predominantly
Neutrophilia 63.9%

11. CARDIAC ECHO
 Not done,
but equally
important

12. CT scans

14. Bony Window,
Sagittal view

15. Bony window,
coronal view

16. Mediastinal Window

20. Lung Window

22. NOT MS. XX

23. CONSTRICTIVE PERICARDITIS
 Pericardium: relatively avascular fibroserous sac
 Constrictive pericarditis occurs when a thickened fibrotic
pericardium, of whatever cause, impedes normal diastolic
filling.
 Often leads to pericardial inflammation, chronic fibrotic
scarring, calcification, and restricted cardiac filling.

24. PATHOPHYSIOLOGY
 Acute and subacute forms of pericarditis (which may or may not be
symptomatic) may deposit fibrin, which, can evoke a pericardial
effusion; often leads to pericardial organization, chronic fibrotic
scarring, and calcification, most often involving the parietal
pericardium.
 In constrictive pericarditis, the easily distensible, thin parietal and
visceral pericardial linings become inflamed, thickened, and fused.
 The ventricle loses distensibility, venous return to the heart becomes
limited, and ventricular filling is reduced, with associated inability to
maintain adequate preload.
 Eventually filling pressures of the heart tend to become equal in both
the ventricles and the atria.

26. ETIOLOGY
 Common causes: TB
 (Purulent bacterial infections: Staph; Pseudomonas; Group A & B
strept; Klebsiella sp; E.coli spp)
 Viral: cocksackie; adenovirus; echovirus
 Idiopathic: Radiation
 Cardiac surgery
 Fungal: coccidioides; aspergillus; norcardia
 Neoplasms
 Uremia
 Connective tissue disorders: SLE
 DRUGS
 Trauma
 MI

27. CLINICAL FEATURES
 Retrosternal chest pain that radiates to the
 Easy fatigability
 Fever
 Tachycardia
 Palpitations
 Paroxysmal nocturnal dyspnea
 Diaphoresis

28. INVESTIGATIONS (SPECIFIC FINDINGS)
 Bloods : signs of infection
 Ecg: PR depression, reduced Q wave voltage
 Xrays
 Echo
 CT

29. MANAGEMENT
 Pericardiectomy is the predominant definitive treatment.
Hemodynamic and symptomatic improvements are rapid.
 Medical management, such as careful observation or
symptomatic treatment, has been suggested in less severe
cases;
 The underlying disease usually determines the prognosis.
Poorer prognoses are associated with malignancy and New
York Heart Association (NYHA) class III or IV heart failure
symptoms.

34. REFERENCES
 J. Alastair, 2016. Davidson’s Essentials of
Medicine, 2nd ed. Churchill Livingstone Elsevier
(pty)
 Radiopenia, 2006.
https://radiopaedia.org/cases/lung-cancer-with-
malignant-pericardial-effusion
 Jae K, at al, Mar 09, 15. Echocardiography
Diagnostic criteria for Constriction. American
College of Cardiology.