A70-14 Crossing Borders, Constricting Hearts: Diagnostic Challenges in Tuberculous Constrictive Pericarditis

Abstract Introduction Tuberculous pericarditis is a rare but serious manifestation of Mycobacterium tuberculosis infection and remains a leading cause of constrictive pericarditis in endemic regions. Despite appropriate anti-tuberculous therapy, up to 60% of patients may develop pericardial constriction, resulting in significant morbidity. Early recognition is essential, yet diagnosis is often delayed due to nonspecific symptoms and low microbiologic yield. Case Presentation A 23-year-old Ethiopian male with no past medical history presented with two weeks of dyspnea, paroxysmal nocturnal dyspnea, and chest pain, associated with night sweats and weight loss. He was hemodynamically stable, but imaging revealed bilateral pleural effusions, a moderate pericardial effusion, mediastinal and hilar lymphadenopathy, and a 1.3-cm right upper lung nodule. A transthoracic echocardiogram (TTE) showed mildly reduced systolic function, pericardial thickness of up to 1 cm, and tethering of the left ventricular apex—suggestive of constrictive pericarditis. Given his clinical picture and epidemiologic risk, active tuberculosis (TB) was strongly suspected. Empiric RIPE therapy and adjunctive corticosteroids were initiated despite negative microbiologic studies, including sputum, pleural fluid, and lymph node tissue. One week later, he returned with worsening dyspnea. Repeat TTE showed progressive biventricular dysfunction, prompting urgent right and left heart catheterization, which demonstrated equalization of diastolic pressures across all chambers and a “square root” sign—hallmark findings of constrictive physiology indicating impaired diastolic filling due to a rigid pericardium. In light of these findings, he underwent pericardiectomy, and pericardial tissue subsequently stained positive for acid-fast bacilli (AFB), confirming tuberculous pericarditis Discussion Tuberculous pericarditis remains an uncommon but important cause of constrictive pericarditis, particularly among immigrants from TB-endemic regions. While it accounts for only ∼4% of pericarditis cases in developed countries, it is the predominant etiology in high-burden areas, representing up to 70% of cases in South Africa. Constrictive pericarditis is its most serious complication, developing in 30-60% of patients even with prompt anti-tuberculous therapy and corticosteroids. Clinical presentation ranges from subtle dyspnea to overt right heart failure and is often missed early in the disease course. Diagnostic confirmation is challenging, as pericardial fluid and tissue cultures have low sensitivity and delayed results. This case underscores the importance of maintaining a high index of suspicion and recognizing characteristic hemodynamic signatures for prompt diagnosis. With rising global migration and persistent TB prevalence, clinicians should remain vigilant for tuberculous pericarditis and its complications. Early identification of constrictive physiology and surgical intervention remain critical to prevent irreversible cardiac dysfunction. This abstract is funded by: None