Images in cardiovascular medicine: Transkei heart

A 16-year-old student from the rural Eastern Cape (former Transkei) was referred to Capetown for cardiovascular evaluation because of a four-month history of progressive dyspnoea and cardiomegaly reported on the chest-X ray. At physical assessment he appeared chronically ill, the blood pressure was 110/ 70 mmHg, the resting pulse rate 114 beats/minute, regular and equal, with pulsus paradoxus of 14 mmHg, and the central venous pressure was raised with a positive Kussmaul’s sign. His lungs were clear, the heart sounds muffled, without a pericardial rub or knock, and the liver was palpable 2 cm below the costal margin.