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Endgames Picture Quiz

Fatigue, facial flushing, and ankle and abdominal swelling in a 53 year old man

BMJ 2008; 337 doi: (Published 30 October 2008) Cite this as: BMJ 2008;337:a2042
  1. Rose Abbott, medical student1,
  2. Harry R Dalton, consultant gastroenterologist12
  1. 1Peninsula College of Medicine and Dentistry, Truro, Cornwall TR1 3LJ
  2. 2Cornwall Gastrointestinal Unit, Royal Cornwall Hospital, Truro, Cornwall TR1 3LJ
  1. Correspondence to: H R Dalton harry.dalton{at}

    A 53 year old man presented with an 18 month history of fatigue, abdominal distension, and ankle swelling. Initial clinical examination, electrocardiography, chest radiography, and blood tests were unremarkable except for his liver enzymes, which showed a cholestatic pattern. Ultrasound and computed tomography scans of his abdomen showed mild hepatomegaly and a trace of ascites. A liver biopsy demonstrated non-specific inflammation and sinusoidal congestion. He recently developed flushing of his ears and face on bending forwards, which takes several minutes to clear on standing. At this stage he underwent magnetic resonance imaging of his chest (fig 1).

    Fig 1 Magnetic resonance imaging scan of the patient’s chest


    • 1. What clinical sign is likely to be present on examination?

    • 2. What is the diagnosis?

    • 3. What are the causes of this condition?

    • 4. How should it be treated?


    Short answers

    • 1. The jugular venous pressure will be raised—sometimes so much so that the ears waggle—and it will fail to fall—or paradoxically rise—on inspiration (Kussmaul’s sign).

    • 2. Constrictive pericarditis. Cardiac magnetic resonance imaging showed a thickened fibrotic pericardium as a black rim around the cardiac silhouette surrounded by white pericardial fat (fig 2). The normal pericardium is usually barely visible on magnetic resonance imaging.

    Fig 2 Cardiac magnetic resonance imaging scan showing a thickened fibrotic pericardium as a black rim around the cardiac silhouette (arrow) surrounded by normal pericardial fat, which is white

    • 3. The condition can be idiopathic or the result of rheumatoid arthritis, cardiac …

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