A rare presentation of th...

A young female in her late 20s, previously healthy, presented to the emergency department
with sudden weakness in her right upper arm. She had also been experiencing giddiness upon
standing, intermittent low-grade fever, and unquantified weight loss for the past month. The
symptom of giddiness slowly progressed in terms of duration. On the day of the weakness
onset, she could not hold a glass of water with her right upper limb and had difficulty
reaching overhead objects. Clinical evaluation revealed decreased power (3/5), exaggerated
deep tendon reflexes in the right upper limb, and right side extensor plantar response. A
cardiovascular examination revealed a mid-diastolic murmur in the mitral area in the upright
position, which disappeared in the supine position. MRI and imaging studies showed
multifocal acute infarcts in her brain (Fig 1). As there was suspicion of a cardioembolic
stroke, a transthoracic echocardiogram was conducted (Fig 2).