Online Clinical Case Study (September 2017)

Clinical Cardiology Series

The content of the September Cardiology Series is provided by:
Dr. WONG Chi Yuen
MBBS (HK), MRCP (UK), FHKCP, FHKAM (Medicine), Specialist in Cardiology
Dr. CHUI Shing Fung
MBChB (CUHK), MRCP (UK), FHKCP, FHKAM (Medicine), Specialist in Cardiology

A 24-year-old lady with abnormal ECG

A 24-year-old lady was referred for assessment of abnormal ECG (Figure 1) as incidental finding on body check. She was asymptomatic at all.

Figure 1


What is shown in the ECG?
 1. Left bundle branch block
 2. Right bundle branch block
 3. Left axis deviation
 4. Right axis deviation

A. 1 and 3
B. 1 and 4
C. 2 and 3
D. 2 and 4
E. None of the above

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Physical examination revealed soft ejection systolic murmur over left upper sternal border. An echocardiogram was arranged (Figure 2 left: apical 4 chamber view; right: same view with color flow imaging). The images showed right ventricular and atrial enlargement, an echo drop out in the interatial septum (arrow) with color flow Doppler demonstrating left to right shunting.

Figure 2

The murmur is related to increased flow across pulmonary valve secondary to the left to right shunt across this defect leading right heart chamber volume overload.

Which of the following is NOT an indication of operative management of this condition?
A. Asymptomatic right ventricular volume overload
B. Symptomatic right ventricular volume overload
C. History of cardioembolism
D. Orthodeoxia-platynea syndrome
E. Severe irreversible pulmonary hypertension


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Is endocarditis prophylaxis required for this patient?
A. Yes
B. No

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1. D, 2. E, 3. B

The diagnosis of this lady is secundum atrial septal defect (ASD) with evidence of right sided cardiac chamber overloading.

ASD is second commonest congenital defect which accounts for about 13% of congenital heart disease. Secundum ASD is the most common type (about 70% of all ASD) and it is more common in female. It is typically located with the fossa ovalis related to arrested growth of secundum septum or excessive resorption of primum septum. The defects may be single or multiple, with great variation in size from few millimeters to larger than 3 centimeters. Other rare types of ASD include primum, sinus venous or coronary sinus defects (Figure 1).

Figure 1.

Many patients with small secundum ASD (< 8 mm) remain asymptomatic and the defect may spontaneously close during childhood. Patients with larger ASD have chronic left to right shunting resulting in right sided chamber volume overloading, and will be more likely to be symptomatic at third or fourth decade if the shunt is significant (e.g. pulmonary to systemic flow ratio > 2:1). Clinical manifestations include dyspnea, exercise intolerance, palpitation related to atrial arrhythmia, stroke or other embolic events due to paradoxical right to left embolism. If untreated, patient may develop severe pulmonary hypertension due to volume overload, and eventually some of them may have irreversible pulmonary hypertension, reversed right to left shunting and Eisenmenger syndrome with cyanosis.

The ECG of patients with secundum ASD may be normal, or there may be RBBB and RAD. The RBBB pattern (which is frequently incomplete) is thought to be due to right ventricular hypertrophy rather than conduction disturbance.

Echocardiogram, usually transthoracic (TTE), is the investigation of choice to detect the presence of ASD and its haemodynamic effect on cardiac chambers and pulmonary pressure. If the TTE images are suboptimal, transesophageal echocardiogram (TEE) should be considered for better assessment. The size of defect, adequacy of tissue rims, relationship with other structures and presence of additional defects are all important information for planning of interventional procedure.

Apart from medical treatment for heart failure, arrhythmia and embolic phenomenon, operative closure of ASD should be considered in symptomatic patients or asymptomatic patients with evidence of right sided chambers volume overload with or without reversible pulmonary hypertension. In contrast, patients with irreversible pulmonary hypertension or Eisenmenger syndrome should not undergo any form of ASD closure. Operative management of secundum ASD could be in the form of surgical patch closure, or more commonly nowadays, percutaneous occluder implantation (Figure 2) in cases with suitable size and anatomy. However in other form of ASD surgical closure remains the mainstay of treatment.

Figure 2.

In patients with acyanotic, unrepaired ASD without prior history of endocarditis, endocarditis prophylaxis is not required. However if the patient has prior repair with residual shunt at the site of prosthesis patch or device, or the patient has catheter-based closure of ASD within 6 months, endocarditis prophylaxis is advised.

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Dermatology Series 皮膚科病例研究

Dermatology Series for September 2017 is provided by:
Dr. CHAN Hau Ngai, Kingsley, Dr. TANG Yuk Ming, William, Dr. KWAN Chi Keung, Dr. LEUNG Wai Yiu and Dr. CHANG Mee, Mimi
Specialists in Dermatology & Venereology

A 15-year-old boy complained of rash over back for few months

A 15-year-old boy with good past health complained of asymptomatic rash over back for few months which was worsening in nature. Physical examination showed well defined linear lesions over back. There was no other body part involved and he was not on any medication.


1. What is the clinical diagnosis?
a. Adolescent striae
b. long term usage of steroid
c. Cushing's syndrome
d. Marfan's syndrome
e. Child abuse
The clinical diagnosis is adolescent striae which are normal pubertal phenomenon and can develop gradually during patients' growth spurt. Differential diagnoses include: long term usage of topical corticosteroid, Cushing's syndrome, Marfan syndrome, child abuse, etc.

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2. What are other areas that this skin disease may occur?
a. Thighs
b. Buttock
c. Breast region
d. Trunk
e. All of the above
Apart from the back. Adolescent striae may develop over thighs, buttocks and breast regions.

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3. This skin disease can be diagnosed clinically. (T/F)
This skin disease is usually diagnosed clinically and no further investigation is needed. The lesions will stop worsening after patients complete their growth development.

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4. This skin condition gets better after topical steroid cream. (T/F)
This skin condition gets worsen after applying topical steroid cream. The first management is to provide reassurance to patients and their family members as these lesions are normal pubertal phenomenon. Topical tretinoin and laser treatment may help to reduce the redness of these lesions. Fractional laser and fractional radiofrequency can help to improve the texture of these lesions.

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