Online Clinical Case Study (April 2011)

Clinical Cardiology Series

The content of the Office Cardiology Series is provided by:
Dr. LI Siu Lung, Steven
FHKAM (Med), FRCP (Glasg), FRCP (Edin), FRCP (Lond), Specialist in Cardiology
Dr. WONG Shou Pang, Alexander
FRCP, FHKAM (Med.), FHKCP, Specialist in Cardiology

A 25-year-old lady with a sudden onset of slurring and weakness in the left limbs

A 25-year-old lady presented with a sudden onset of slurring of speech and weakness in her left upper and lower limbs. She was a non-smoker with good past health, and was not on oral contraceptive pills or other drugs. Her cholesterol and glucose levels were normal with a normal blood pressure.

Figure 1

Figure 2



What further investigations would you perform?
a. CT/MRI brain scan
b. Doppler carotid arteries
c. ECG
d. Echocardiogram
e. All are correct

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What is the abnormality in Figure 1?
a. Intracranial haemorrhage
b. Cerebral infarct
c. Brain abscess

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A trans-oesophageal echocardiogram was done. What is the abnormality in Figure 2?
a. Infective endocarditis with vegetation
b. Cor triatriatum in the left atrium
c. Atrial septal defect

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What should be the long-term treatment?
a. Surgical repair/resection
b. Anti-coagulation therapy
c. Antibiotics




Cerebrovascular accident is uncommon in this age group, particularly in patients with no common risk factors for atherosclerosis. Causes are often cryptogenic but they may include cerebrovascular anomalies and cardiac causes. Cerebrovascular anomalies may include arteriovenous malformation and cerebral aneurysm. Cardiac causes may include thromboembolism due to atrial fibrillation, intra-cardiac shunt and intracardiac thrombus.

The trans-oesophageal echocardiogram of this lady revealed a cor triatriatum in the left atrium. A cor triatriatum is a rare congenital anomaly which takes the form of a thin membrane in the atrium, thereby partitioning the atrium into two halves. Cor triatriatum has been reported as a rare cause of thromboembolic stroke. Sometimes there may be an opening in the membrane, creating a functional stenosis across the membrane, which further predisposes thrombus formation.

In this patient, the trans-oesophageal echocardiogram was done after a few days of low molecular heparin therapy, which may have partially dissolved any intra-cardiac thrombus. Nevertheless, a small thrombus-like shadow was still noted near the centre of the membrane. Surgical resection is one way for secondary prevention. If a non-invasive approach is preferred, life-long anti-coagulation therapy is necessary.

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Dermatology Series 皮膚科病例研究

A lady with an itchy patch on her cheek

A 28-year-old woman, who had enjoyed good past health, presented with chronic itchy, dry patches on her left cheek for four months. Sun exposure accentuated the lesions occasionally. She was diagnosed wi th al lergic contact dermatitis and was treated with topical steroids by her family doctor. Her condition improved for a short while but worsened one week after commencing the treatment. Physical examination showed multiple annular erythematous scaly patches with an active border of papules and vesicles on her cheek and jaw line.

The content of the Dermatology Series is provided by:
Dr. LEUNG Wai Yiu, Dr. CHAN Hau Ngai, Kingsley, Dr. TANG Yuk Ming, William and Dr. KWAN Chi Keung
Specialists in Dermatology & Venereology



What are the diagnosis and differential diagnoses?

Tinea faciei. Differential diagnoses include atopic dermatitis, contact dermatitis, seborrhoeic dermatitis, psoriasis, cutaneous lupus erythematous, rosacea, and pityriasis rosea.

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How do you confirm the diagnosis?

Tinea faciei is diagnosed by direct microscopic examination of a potassium hydroxide- (KOH-) treated scraped skin specimen for fungal hyphae and/or fungal culture.

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What are the common causative agents?

Common dermatophytes include Trichophyton mentagrophytes, T. rubrum, T. tonsurans and Microsporum canis.

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What are the treatments?

Topical treatment is effective for small areas of tinea faciei. However, for refractory or extensive lesions, as has occurred in this patient, systemic antifungal therapy should be employed. Griseofulvin, itraconazole and terbinafine work well for tinea faciei.

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