A rare case of constrictive pericarditis with Budd-Chiari syndrome due to right atrial thrombosis

Patients living with HIV (PLWH) with previous pulmonary tuberculosis, presenting with disproportionate ascites to peripheral congestion, should alert the clinician to consider constrictive pericarditis and Budd-Chiari syndrome (BCS). Constrictive pericarditis is the scarring and loss of the pericardial sac elasticity. The aetiology of constrictive pericarditis varies between developed and developing countries, with infective causes like tuberculosis being significant in South Africa. Budd-Chiari syndrome is a group of disorders characterised by hepatic venous outflow obstruction. The level of obstruction in Budd-Chiari syndrome varies globally. In Asia, South Africa, India, and China, obstruction is predominantly found in the inferior vena cava while in Western countries, hepatic vein obstruction occurs. Patients living with HIV are at increased risk of arterial and venous thromboembolism. The clinician must consider Budd-Chiari syndrome in patients living with HIV presenting with ascites. In patients living with HIV, tuberculosis co-infection has been associated with a higher risk of pericarditis. Both constrictive pericarditis and Budd-Chiari syndrome share a remarkably similar clinical presentation, with ascites and hepatomegaly. There is a dearth of literature on co-existent constrictive pericarditis and Budd-Chiari syndrome. We describe a 31-year-old HIV-infected female, on anti-retroviral therapy (CD4 count 208 cells/uL, undetected viral load), with previous pulmonary tuberculosis, who presented with a 2-month history of abdominal swelling, peripheral oedema, and New York Heart Association grade 4 dyspnoea. Examination revealed an elevated jugular venous pulsation with CV waves, atrial fibrillation, right-sided S3 gallop, pansystolic murmur (3/6) at the left sternal border, tender hepatomegaly, and massive ascites with minimal peripheral oedema. The discordant size of ascites prompted investigations, namely, ultrasound abdomen, echocardiogram, and computed tomography (chest and abdomen). These revealed constrictive pericarditis and Budd-Chiari syndrome with thrombus formation in the right atrium, hepatic vein, and inferior vena cava. She was initiated onto anti-coagulation, anti-tuberculosis therapy and referred for pericardiectomy. Clinicians must maintain a suspicion for constrictive pericarditis and Budd-Chiari syndrome in HIV-infected patients, especially in those with a previous tuberculosis, presenting with features of right heart failure.