Severely calcified pericardium as post tuberculosis sequale

A 61-year-old lady from a rural area in Sabah, Malaysia, complained of progressive worsening of dyspnea, peripheral edema, paroxysmal nocturnal dyspnea, and palpitation of 4 months duration. She had completed treatment for disseminated tuberculosis 40 years ago. On clinical examination, presence of pulsus parodoxus and Kausmall sign with a pericardial knock on auscultation. The respiratory system examination revealed reduced chest expansion, dull on percussion and reduced breath sound on the right side of lung. Her blood investigation was normal including erythrocytes sendimentation rate (ESR). Her electrocardiograph (ECG) showed atrial fibrillation with no other significant findings. Chest X-ray (Figure 1) showed normal heart size with diffused calcification encasing the heart with partial collapse of the right lung. Her echocardiography showed diffusely bright and thickened pericardium. Computed topography (CT) thorax showed chronic TB changes with calcification within the pericardium (Figure 2). She was diagnosed with constrictive pericarditis as a sequelae of previous disseminated tuberculosis. Specific therapy was discussed however she refused for surgical intervention. She is currently attending outpatient follow-up with medical therapy. Tuberculosis is endemic in Malaysia, and the incidence of the case in 2015 was 79 per 100 000 [1]. Calcified pericardium is a recognized sequelae of tuberculosis, it occurred up to 1%–2% of tuberculosis patients [2]. In our patient, there was the presence of pericardial knock, which is a specific physical sign of constrictive pericarditis [3]. Our patient’s presentation of tuberculosis pericarditis was late as she developed symptoms of constrictive pericarditis and calcified pericardium. The calcified pericardium is a marker of chronicity of the illness; therefore, early pericardiectomy with antituberculosis coverage is recommended [3]. In conclusion, early diagnosis and treatment in patients with tuberculosis pericarditis are important to prevent the long-term sequelae of this disease. Diffuse pericardial calcification with right lung collapse. Cardiac CT scan showed high degree of pericardial calcification involving both right and left ventricle. None. All author does not have any conflict of interest to disclose. No funding were received for this work. No ethical approval was obtained. Informed consent was obtained from the patient. This work does not contain any personal information that could lead to the identification of the patient. Dr. Liew Houng Bang.