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case_images: Images on the right display. (A) Right pleural effusion and significant pericardial thickening without calcification are seen on computed tomography. (B) Reduced right ventricular ejection fraction, diastolic dysfunction, and pericardial thickening are seen on echocardiography. (C) A 'Dip and plateau' pattern with equalization of bilateral ventricular end-diastolic pressures are revealed on hemodynamic cardiac catheterization. (D) Increased counts of IgG4-positive plasma cells are seen on immunostaining of the resected pericardium.
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case_images: Electrocardiography showed sinus rhythm with prominent mitral P waves (Figure 1A). Chest radiography revealed a cardiothoracic ratio of 52.7% and a blunted right costophrenic (Figure 1B). Computed tomography (CT) identified right-sided pleural effusion, ascites, and significant pericardial thickening without calcification (Figure 1C).
case_images: (A) Electrocardiography shows sinus rhythm and prominent mitral P waves. (B) Mild cardiomegaly and a right blunt costophrenic angle are identified on chest radiography. (C) Computed tomography shows right pleural effusion and significant pericardial thickening without calcifications.
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case_images: Furthermore, ultrasound echocardiography showed a reduced left ventricular ejection fraction (47%) and pericardial thickening (Figure 2A and B, arrowheads; Supplementary material online; Supplementary material online, Videos S1 and S2). Neither remarkable respiratory septal shift (septal bounce) nor significant respiratory variations were observed in the transmitral (Figure 2C) and transtricupsid flow patterns (Figure 2D).
case_images: (A, B) Ultrasound echocardiography shows reduced right ventricular ejection fraction, diastolic dysfunction, and pericardial thickening (arrowheads). Respiratory variations are absent in the transmitral (C) and transtricupsid flow patterns (D).
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case_images: Haemodynamic cardiac catheterization revealed a 'dip and plateau' pattern (Figure 3A) with equalization of the bilateral ventricular end-diastolic pressures (Figure 3B). CP and right-sided heart failure. Coronary angiography identified absent organic stenoses and highly fixed, unsynchronized coronary arteries (Figure 3C and D, Supplementary material online, Videos S3 and S4).
case_images: Haemodynamic cardiac catheterization demonstrates a 'dip and plateau' pattern (A) and equalization of bilateral ventricular end-diastolic pressure (B). (C, D) Coronary angiography shows absent organic stenoses and highly fixed, unsynchronized coronary arteries (arrow range).
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case_images: Pathological examination of the resected pericardium revealed partial lymphocyte infiltration and prominent fibrosis (Figure 4A and B). Immunostaining demonstrated a substantial increase in IgG4-positive plasma cells (70 cells per high-power field in the most affected area) and an elevated IgG4/IgG-positive cell ratio (<=70%) (Figure 4C and D).