Constrictive pericarditis presenting with massive ascites without hemodynamic echocardiographic features

A 27-year-old woman presented to the hospital because of a five-month-history of rapidly-accumulating ascites, dyspnea, and fatigue. The patient was otherwise asymptomatic, and required repeated large volume paracenteses. Physical exam was benign except for hepatomegaly and abdominal distension. Laboratory testing demonstrated elevation of transaminases, but further testing was all negative. A chest CT showed pericardial thickening. Subsequent echocardiography was performed to evaluate for constrictive pericarditis, but apart from inferior vena cava (IVC) dilation, there were no other findings suggestive of pericardial constriction. A subsequent cardiac catheterization was suggestive of constrictive pericarditis, so the patient underwent a pericardiectomy. The Mayo Clinic echocardiography diagnostic criteria presents a diagnostic paradigm where the presence of mitral inflow E/A > 0.8 and the presence of a dilated IVC concomitantly provide good sensitivity for echocardiographic diagnosis of constrictive pericarditis (CP). Due to the good sensitivity and specificity of echocardiographic findings, the lack of any characteristic finding is surprising, and suggests the importance of other diagnostic modalities such as CT, cardiac MRI, and cardiac catheterization in conjunction with echocardiography when there is a high suspicion for CP.