Tuberculous Myopericarditis With Constrictive Physiology: A Case Report Using a Multimodality Approach

Tuberculous pericarditis is a rare but important cause of constrictive pericarditis in developed countries, while remaining a significant public health concern in endemic regions. Myocardial involvement is uncommon and often underrecognized. A previously healthy 47-year-old man presented with a five-year history of progressive bilateral lower-limb edema and exertional dyspnea, with marked deterioration over the last five months, including severe fatigue and involuntary weight loss of 8 kg. On admission, imaging revealed biventricular systolic dysfunction, pericardial thickening with calcifications, and bilateral pleural effusions. Pleural fluid analysis demonstrated an exudative effusion with markedly elevated adenosine deaminase (ADA) levels (130 U/L), consistent with tuberculous pleuritis. Cardiac magnetic resonance imaging confirmed myopericarditis with diffuse pericardial thickening (up to 6 mm) and late gadolinium enhancement. Right heart catheterization demonstrated findings consistent with constrictive physiology. Given the presence of severe ventricular dysfunction, atrial fibrillation, and active extrapulmonary tuberculosis, pericardiectomy was deferred. Antituberculous therapy and guideline-directed medical treatment for heart failure were initiated. At three-month follow-up, the patient demonstrated mild functional improvement and continued on a standard six-month antituberculous regimen, which was ongoing at the time of reporting. In endemic areas, tuberculosis should be considered an important cause of constrictive pericarditis in patients with unexplained pericardial disease. Multimodality imaging is essential for accurate diagnosis and for guiding management, especially in complex presentations involving both the pericardium and myocardium. This case illustrates the diagnostic value of a multimodality approach and the management strategy in a high-risk surgical candidate.