A 30-year-old gentleman presented with a history of progressive dyspnoea with distension of abdomen, pedal edema and loss of weight of 1 month duration. Clinical examination revealed raised jugular venous pressure with rapid y descent and Kussmaul's sign. ECG showed low-voltage complexes. Chest X-ray [Figures 1a and b] showed normal cardiac size with calcification of the pericardium. 2D echocardiography was suggestive of chronic constrictive pericarditis. Computed tomography of the thorax showed heavy egg shell calcification of the pericardium mimicking snow fall on mountain appearance [Figures 2a and b, 3a and b]. Patient underwent successful pericardiectomy with dramatic improvement in dyspnoea, ascites, and pedal edema. Computed tomography is the gold standard imaging tool for cardiac calcification especially involving the pericardium.
Figure 1.
a) Chest X-ray, PA view and b) lateral view, show pericardial calcification along anterior and interior borders
Figure 2.
a) Computed tomography, sagittal view and b) coronal view show egg-shell calcification of the pericardium
Figure 3.
a) AP View, b) lateral view. Computed tomographic volume rendered image showing dense egg-shell calcification of the pericardial mimicking “snow fall on mountain” appearance
DISCUSSION
Pericardial calcification is a common finding in patients with constrictive pericarditis. Careful examination of chest X-ray may raise the suspicion of calcific constrictive pericarditis. Standard chest CT-scan allows a nice anatomic delineation of the pericardium and its calcifications. Furthermore, computed tomography best defines the often asymmetric degree of pericardial thickening or calcification, which may be important in determining the optimal surgical approach for pericardial resection.[1] It is often associated with idiopathic disease and other markers of disease chronicity and is an independent predictor of increased perioperative mortality rates.[2] However the definitive diagnosis relies on a careful hemodynamic evaluation by right and left heart catheterization including respiratory recordings of RV and LV pressure changes.[3]
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