A 30-year-old woman with a history of HIV and HCV presented to the emergency department with a 4-month history of gradual but progressive swelling of her lower limbs and abdomen.

She denied any chest pain, dyspnoea, paroxysmal nocturnal dyspnoea or orthopnoea.

Vitals were stable.

Cardiovascular examination was remarkable for an elevated jugular venous pressure (JVP) of about 12 cm with a pronounced ‘y’ descent.

There was a prominent pericardial knock sound heard over the praecordium.

There was no pericardial rub or murmur.

The lungs were clear to auscultation.

The patient was markedly oedematous from the abdomen to the lower limbs.

She was admitted for further diagnostic work-up and management.

She was diagnosed with HIV around May 2010 and had been on antiretroviral therapy.

She had not used illicit drugs for approximately 5–6 years.

Renal and hepatic diseases were ruled out through blood tests and imaging.

Peritoneal fluid was negative for malignancy.

Echocardiogram showed a thickened bright pericardium adjacent to the right heart border (figure 1) with parallel separation between epicardial and pericardial echoes (railroad track sign), septal bounce and lack of pericardial slide.

Annulus paradoxus was demonstrated on tissue Doppler (figure 2).

Left ventricular ejection fraction was 64%.

The right ventricle was normal in size and function.

There was moderate tricuspid regurgitation.

There was no pericardial effusion, but the pericardial space was remarkable for debris.

Constrictive physiology was demonstrated by Doppler study of tricuspid and mitral inflows (figure 3) during inspiration and expiration; diastolic flow reversal was also demonstrated in the hepatic veins during expiration.

There was marked dilatation of the inferior vena cava with no change during inspiration or expiration.

CT of the chest revealed thickening of the pericardium with no evidence of calcification.

There were no lung nodules.

Bilateral pleural effusions and interstitial thickening were present in the lung bases.

Cardiac MRI confirmed the presence of a diffusely thickened pericardium at 5 mm.

The inferior vena cava and hepatic veins appeared plethoric.

There was a rapid early diastolic filling and associated diastolic septal bounce secondary to hindered late diastolic filling (figure 4).

The patient showed a good response to diuresis.

She underwent right and left heart catheterisation to confirm constrictive physiology.