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+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.