When Tuberculosis Left the Heart in a Cage: Multimodality Imaging Revealing Constrictive Pericarditis in a Young...

Tuberculous pericarditis (TBP) is a potentially severe manifestation of extrapulmonary tuberculosis that may lead to pericardial effusion and constrictive physiology and, in some patients, progress to fixed constrictive pericarditis. Diagnosis can be particularly challenging in young immunocompetent patients without overt pulmonary involvement. We report the case of a 20-year-old immunocompetent man presenting with a one-month history of weight loss, profuse night sweats, nocturnal fever, and typical pericarditic chest pain. Clinical examination revealed fever and signs of systemic venous congestion. Transthoracic echocardiography demonstrated marked pericardial thickening, moderate circumferential effusion, septal bounce, approximately 25% respiratory variation in transmitral flow, annulus reversus, and annulus paradoxus, supporting the presence of pericardial effusion with constrictive physiology. Contrast-enhanced computed tomography confirmed diffuse pericardial thickening and effusion without calcification or pulmonary parenchymal involvement. At the same time, cardiac magnetic resonance demonstrated intense late gadolinium enhancement of the thickened pericardium, supporting active pericardial inflammation. Xpert Mycobacterium tuberculosis/Rifampicin assay (Xpert MTB/RIF; Cepheid, Sunnyvale, CA, USA) testing of the pericardial fluid detected Mycobacterium tuberculosis, subsequently confirmed by positive mycobacterial culture. Following multidisciplinary discussion, a six-month antituberculous regimen combined with adjunctive corticosteroid therapy was initiated, with close clinical and multimodality imaging follow-up and reassessment for pericardiectomy according to clinical evolution. This case highlights the complementary value of echocardiography, computed tomography, and cardiac magnetic resonance in characterizing tuberculous pericardial disease associated with constrictive physiology and defining its inflammatory substrate. Identification of active pericardial inflammation in the presence of constrictive physiology may indicate a potentially reversible component; however, actual reversibility requires confirmation during longer-term follow-up.