Hiding in plain sight; constrictive pericarditis.

We present a case of constrictive pericarditis that was especially difficult to diagnose. The patient presented with generalised oedema, dyspnoea and pleural effusions. History was significant for prior polysubstance abuse but was otherwise unremarkable. Physical examination revealed only jugular venous distention. CT demonstrated a normal pericardium with pleural effusions. Echocardiography showed mildly elevated right ventricular pressures with dyssynergic motion of the ventricular septum. No intervention was being carried out, but 1 month later further evaluation with a right and left heart catheterisation showed the classical square-root sign with equalisation of diastolic pressures in both ventricles as well as ventricular interdependence. Idiopathic constrictive pericarditis was thus diagnosed with a subsequent pericardial stripping which confirmed a thickened pericardium encasing the heart.