When Tuberculosis Left the Heart in a Cage: Multimodality Imaging Revealing Constrictive Pericarditis in a Young Adult

Figures

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  Figure 1. Chest radiograph showing cardiopericardial silhouette enlargement Chest radiograph showing an enlarged cardiopericardial silhouette, without visible pericardial calcification or focal pulmonary parenchymal abnormalities.

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  Figure 2. Transthoracic echocardiographic findings of pericardial involvement. (A) Apical four-chamber view showing thickening of the parietal pericardium (yellow star) and visceral pericardium (blue star), with associated pericardial effusion (red arrow); (B) Subcostal view demonstrating marked thickening of the parietal pericardium (yellow star, 7 mm) and visceral pericardium (blue star, 6 mm), with associated pericardial effusion (red arrow); (C) Subcostal view showing pericardial effusion adjacent to the cardiac apex, with a maximal end-diastolic separation of 17 mm (red arrow).

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  Figure 3. Doppler echocardiographic features of constrictive physiology (A) Pulsed-wave Doppler of transmitral inflow showing an E-wave velocity of 0.58 m/s, an A-wave velocity of 0.36 m/s, and an E/A ratio of 1.77, with approximately 25% respiratory variation in E-wave velocity, a borderline finding considered supportive of constrictive physiology; (B–C) Tissue Doppler imaging of the mitral annulus showing a lateral e′ velocity of 0.13 m/s (B) and a septal e′ velocity of 0.17 m/s (C). The higher septal than lateral e′ velocity demonstrates annulus reversus, while the preserved septal e′ velocity with a low E/e′ ratio is consistent with annulus paradoxus. Together with the other echocardiographic findings, these features support constrictive physiology.

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  Figure 4. Contrast-enhanced CT demonstrating pericardial thickening and effusion. Contrast-enhanced axial chest computed tomography (CT) showing a circumferential pericardial effusion (red arrows) associated with pericardial thickening (yellow arrow). Small bilateral pleural effusions are also present (blue arrows). No visible pericardial calcification is identified.

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  Figure 5. Cardiac magnetic resonance imaging findings of pericardial involvement Cine cardiac magnetic resonance (CMR) sequences in the (A) short-axis, (B) four-chamber, and (C) three-chamber views demonstrating a circumferential pericardial effusion (red arrows) associated with marked thickening of the visceral (blue stars) and parietal (yellow stars) pericardial layers. Bilateral pleural effusions are also visible in the four-chamber view (B, blue arrows).

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  Figure 6. Late gadolinium enhancement cardiac magnetic resonance findings of active pericardial inflammation Late gadolinium enhancement (LGE) images in the (A) two-chamber, (B) four-chamber, and (C) three-chamber views demonstrate intense enhancement of the thickened pericardium (yellow arrows), consistent with active pericardial inflammation, associated with a circumferential hypointense pericardial effusion (red arrows).