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Coconut heart in a child

      Constrictive pericarditis is rare in the pediatric age group. Calcification is furthermore uncommon. However, calcification in constrictive pericarditis has been seen as a complication following tuberculosis. We present a case of 11-year-old female child, who had a history of active tuberculosis on anti-tubercular treatment. Frontal chest radiograph revealed evidence of pericardial calcification. (shown by black arrow in Fig. 5). Transthoracic echocardiography revealed restricted filling of the hypercontractile left ventricle, dilated inferior vena cava, highly variable mitral inflow pattern. Computed tomography angiography revealed diffuse non-uniform, thickened and densely calcified pericardium (shown by white arrows in Fig. 1A & B, in volume rendered images in Fig. 2A–C shown by white arrows). Biatrial dilatation with tubular shaped ventricles (Fig. 1B) were present. Functional analysis of the left ventricle showed classical sign of “septal bounce” in early diastolic phase. (Supplemental video 1 & 2) Superior vena cava, inferior vena cava, main pulmonary artery were dilated. No radiological signs of active tuberculosis was seen in lung window images. In the visualized sections of upper abdomen, there was hepatosplenomegaly (Fig. 3, Fig. 4). Main portal vein was absent and it was replaced by multiple collateral veins suggestive of portal cavernoma formation (shown by black arrow in Fig. 3, Fig. 4A). There were early changes of portal biliopathy in the form of dilated central common bile duct & dilated left sided intrahepatic billary radicle (shown by white thick arrow in Figs. 3B & 4B), splenomegaly (shown by white arrow in Fig. 3B). Mild ascites with multiple subcentimetric mesenteric and retroperitoneal lymph nodes were present. This patient underwent a course of antitubercular therapy followed by pericardiectomy with significant improvement in patient's clinical condition.

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