We describe the case of a 49-year-old female with a history of pericardial calcification, coronary artery disease, and multiple and chronic obstructive pulmonary disease who presented with a several-day history of worsening shortness of breath. On exam, she was noted to have Kussmaul's sign:impaired jugular vein distension:up to mid-neck, wheezing, and abdominal distention.
On the echocardiogram, she was found to have ventricular interdependence, significant respirophasic variation on the mitral valve, diastolic hepatic vein reversal, and a dilated noncollapsible inferior vena cava (Figure 1). She underwent a coronary angiogram, which showed nonobstructive coronary artery disease but severe pericardial calcifications (Figure 2). A right heart catheterization was not performed due to the echocardiographic findings that were highly suggestive of CP physiology. On CT of the chest, she was found to have severe pericardial calcifications (Figures 3, 4). On cardiac MRI, she was found to have abnormal septal motion of the sigmoidization, septal bounce, and flattening during early diastole. Autoimmune workup (including an antinuclear antibody panel and rheumatoid factor) were negative along with erythrocyte sedimentation rate and C-reactive protein biomarkers. She tested negative for tuberculosis, had no cardiac surgery history, and no history of radiation. She did report a significant history of chest trauma with multiple motor vehicle accidents (with the first being in 2000 and the latest in 2016) and blunt force trauma due to altercations. She had been trialed on nonsteroidal anti-inflammatory drugs (5-day therapy of ketorolac), as well as steroids (5-day therapy of prednisone 40 mg daily), with no relief. She successfully underwent pericardiectomy with resolution of her symptoms. Pericardial biopsy showed fibroconnective tissue with extensive calcifications.