Fatigue, facial flushing, and ankle and abdominal swelling in a 53 year old man

A 53 year old man presented with an 18 month history of fatigue, abdominal distension, and ankle swelling. Initial clinical examination, electrocardiography, chest radiography, and blood tests were unremarkable except for his liver enzymes, which showed a cholestatic pattern. Ultrasound and computed tomography scans of his abdomen showed mild hepatomegaly and a trace of ascites. A liver biopsy demonstrated non-specific inflammation and sinusoidal congestion. He recently developed flushing of his ears and face on bending forwards, which takes several minutes to clear on standing. At this stage he underwent magnetic resonance imaging of his chest (fig 1⇓). Fig 1 Magnetic resonance imaging scan of the patient’s chest ### Short answers Fig 2 Cardiac magnetic resonance imaging scan showing a thickened fibrotic pericardium as a black rim around the cardiac silhouette (arrow) surrounded by normal pericardial fat, which is white