Case Presentation: A 65-year-old man presented with anasarca and dyspnea on exertion that progressively worsened over three weeks. He had no known cardiac, renal, or liver disease prior to presentation. Physical exam revealed elevated jugular venous distention, bibasilar crackles, tense ascites, scrotal edema, and pitting edema in bilateral lower extremities extending to the abdomen. Investigation for an underlying chronic liver disease was pursued due to the presence of a nodular liver on cross-sectional imaging, thrombocytopenia, and coagulopathy. Laboratory tests were suggestive of possible autoimmune liver disease with an elevated anti-smooth muscle antibody and globulin fraction; however, ascitic fluid analysis showed an elevated SAAG with an elevated protein level. Initial echocardiogram did not show evidence of cardiac dysfunction. Since these findings were contradictory regarding the etiology of the ascites (one suggesting liver disease and the other suggesting cardiac disease), patient underwent liver biopsy which showed significant sinusoidal dilation but no evidence of autoimmune hepatitis. Given the suspicion for cardiac dysfunction contributing to patient’s presentation, a cardiac MRI was obtained showing focal pericardial calcification in the mid right ventricle and mild right apical pericardial thickening causing focal constriction. Constrictive pericarditis was diagnosed.

Discussion: Constrictive pericarditis is caused by chronic inflammation leading to scaring and calcification of the pericardium ultimately resulting in loss of pericardial elasticity. Patients may present with JVD, dyspnea, fatigue, peripheral edema, and abdominal swelling thought to be due to protein-losing enteropathy. Diagnosing constrictive pericarditis can be difficult due to its often insidious onset and vague symptoms, but delay in diagnosis can lead to significant morbidity and mortality. Initially patients often exhibit non cardiac symptoms that prompt referral to specialties such as gastroenterology as many of these symptoms can also occur in liver disease, intraabdominal malignancies, as well as other cardiac disorders.

Conclusions: The majority of patients with new-onset ascites have underlying cirrhosis, accounting for upwards of 80% of total cases. A smaller proportion of these cases may be due to an underlying cardiac abnormality. Constrictive pericarditis is often misdiagnosed and requires high clinical suspicion before it is correctly diagnosed. An elevated protein level in the ascitic fluid is highly suggestive of cardiac ascites; therefore, even in the presence of a normal echocardiogram, the diagnosis must still be considered. A cardiac MRI is often needed to accurately make this elusive diagnosis.