The heart in an eggshell

A 41-year-old woman presented with recent onset of abdominal distension and swelling of feet along with New York Heart Association Class III dyspnoea on exertion. Her blood pressure was 100/60 mmHg. The jugular venous waveforms were elevated till the angle of her jaw. The x-descent was conspicuous and the y-descent was visible. The precordium showed mild lateral systolic retraction. There was no pulmonary hypertension. ECG showed 1 mm ST depression and T inversion in inferolateral leads and no pathological Q waves. Chest X-ray revealed a radiopaque shadow around the heart [Figure - 1]a. A plain CT scan of the chest showed the heart almost completely encased in a calcific shell [Figure - 1]b. There was no history of tuberculosis. A diagnosis of calcific constrictive pericarditis was confirmed.^[1] The coronary arteries were normal on angiography. A fluoroscopic projection at the time of coronary angiography before pericardiectomy revealed a characteristic black-egg sign (video available at www.nmji.in). The patient underwent surgical pericardiectomy with relief of symptoms and is doing well on follow-up. The use of plain anteroposterior fluoroscopic projection potentially permits a diagnosis of calcific constrictive pericarditis during coronary angiography without the need for a CT scan.

Figure 1: (a) Chest X-ray in posteroanterior projection showing a radiopaque shadow around the heart. Mild pulmonary venous congestion is evident. Distended superior vena cava is also seen, (b) Plain CT scan shows the heart almost fully encased in a calcific shell. Video (available at www.nmji.in): Fluoroscopic projection in anteroposterior view showing a dark shadow encasing the heart (black-egg sign)

Conflicts of interest. None declared