Cardiac Tamponade as Initial Presentation of Limited Systemic Sclerosis with Pulmonary Hypertension: Multimodal Imaging and Hemodynamic Assessment

Background: Systemic sclerosis (SSc) can involve the heart with varied manifestations. Cardiac tamponade as a presenting feature is rare and poses diagnostic and therapeutic challenges. Multimodality imaging and hemodynamic evaluation guide management. Case summary: A 49-year-old woman was admitted with signs of cardiac tamponade. Pericardiocentesis was performed, yielding serosanguineous fluid with inflammatory features. Right heart catheterization revealed combined post- and pre-capillary pulmonary hypertension (mean pulmonary artery pressure 38 mmHg, pulmonary artery wedge pressure 22 mmHg, pulmonary vascular resistance 3.8 Wood units). Clinical, serologic, and capillaroscopy findings confirmed limited cutaneous systemic sclerosis. Cardiac MRI showed preserved biventricular function with patchy mid-wall late gadolinium enhancement indicative of myocardial fibrosis without edema. Immunosuppressive therapy combined with pulmonary vasodilators was initiated. One-year follow-up demonstrated clinical and hemodynamic improvement.