Qatar Medical Journal - Volume 2025, Issue 2

Background: This umbrella review aims to synthesize evidence from previously conducted meta-analyses and review articles to assess the effects of bempedoic acid on lipid profile and cardiovascular events.

Methods: While adhering to the Preferred Reporting Items for Overviews of Reviews guidelines, PubMed, Google Scholar, Web of Science, and Scopus were searched from the database inception to June 2024 to identify relevant articles. The outcomes were total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), non-HDL cholesterol, triglyceride (TAG), apolipoprotein B (APOB), high-sensitivity CRP (hs-CRP), major cardiovascular events (MACE), cardiovascular mortality, and myocardial infarction (MI). A corrected covered area (CCA) assessment was performed to determine overlap among reviews. Each included review was assessed for its quality and rigor via the AMSTAR-2 tool.

Results: From 18,297 articles identified during the literature search, 18 meta-analyses were included. A significant overlap was noted across studies with a corrected cover area of 44.4%. Bempedoic acid’s effects on cardiovascular outcomes and lipid levels have been extensively studied. For cardiovascular mortality, the evidence is mixed: Goyal et al.²¹ reported a risk ratio (RR) of 0.81 (95% CI 0.61–1.08) suggesting a potential benefit, while other studies, such as De Filippo et al.²⁶ and Zhang et al.²⁴, indicate no significant association. In terms of MACE, 11 reviews show a consistent trend toward reduced risk, with RRs between 0.75 and 0.88. Bempedoic acid also appears to significantly reduce the risk of MI, with RRs and odds ratios (ORs) around 0.76. Evidence on unstable angina suggests a lower risk, although some studies do not reach statistical significance. For coronary revascularization, the data show a reduced risk, with RRs ranging from 0.74 to 0.82. Studies on coronary non-revascularization also indicate a significant risk reduction with RRs and ORs of 0.41. Regarding lipid levels, bempedoic acid consistently reduces LDL cholesterol (mean differences [MDs] from −17.5% to −33.91%), total cholesterol (MDs from −12.69% to −34.41%), and non-HDL cholesterol (MDs from −12.3% to −23.27%). The effects on HDL cholesterol are less consistent (MDs from −1.29% to −5.18%), and triglyceride levels show variable results (MDs from −8.35% to +5.23%).

Conclusion: Our findings show that bempedoic acid significantly reduces the risk of MACE, nonfatal MI, coronary and noncoronary revascularization, and hospitalizations for unstable angina. While results on cardiovascular mortality are mixed, suggesting a need for further study, bempedoic acid proves to be an effective treatment for improving lipid profiles and reducing cardiovascular events, especially in patients who cannot tolerate statins. It presents a valuable option for cardiovascular risk management, potentially enhancing patient outcomes and quality of life. Further research is needed to assess its long-term benefits and broader applicability.

Background: Monkeypox (Mpox) was identified as a virus endemic to Central and Western Africa. Since 2022, the virus has gained global attention due to increasing cases in non-endemic countries among patients having no link to travel to endemic areas. The virus is primarily transmitted through animal-to-human contact but has increasingly spread via human-to-human transmission. A comprehensive understanding of the epidemiology of Mpox in the Middle East and North Africa (MENA) region is essential for effective disease prevention, diagnosis, surveillance, and control.

Methods: This review investigates historical data and recent global and regional epidemiological trends of Mpox. The review discusses the clinical features, public health challenges, and preventive measures relevant to the MENA region using updated data from World Health Organization (WHO) reports, national health statistics, and additional relevant resources.

Results: Mpox cases significantly spread globally during the 2022–2024 period. The MENA region has a relatively low number of documented cases, with 857 confirmed cases by August 2024. Saudi Arabia and the United Arab Emirates (UAE) reported the highest case numbers, reflecting effective surveillance and case detection. However, new cases of Mpox were announced in September 2024 in Morocco and Jordan following the WHO’s declaration of Mpox as a public health emergency of international concern.

Conclusion: The current number of cases in the MENA region could be underestimated due to underreporting, stigmatization, limited resources, and ongoing conflicts in several countries. It is essential to prioritize the containment of the outbreak, exploring all possible strategies to protect vulnerable communities.

Introduction: Malignant otitis externa (MOE) is an aggressive infection of the external auditory canal and the underlying bony structures of the skull base. Predominantly caused by Pseudomonas, the treatment has shifted from surgical to medical, with antimicrobial therapy being primary, although surgical intervention may still be required. This review aims to provide global prevalence and mortality data on MOE to help institutions establish treatment benchmarks.

Methods: A systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines. Searches were completed in Scopus and PubMed Databases for articles on MOE mortality published between 1994 and 2022. Publications included data on MOE, mortality, and all genders.

Results: A total of 22 studies involving 9,633 patients diagnosed with MOE were analyzed. The gender distribution was nearly equal, with 4,819 (50.1%) males and 4,814 (49.9%) females. The patients’ ages ranged from 18 to 90 years, with a mean age of 70.3 years. The pooled period prevalence of mortality due to MOE was estimated to be 18% (95% confidence interval: 6–30%), highlighting a significant mortality risk in patients with this condition. Heterogeneity across the studies was high (I² = 99%, p < 0.001). Additionally, the prevalence of comorbidities was significant: 57.1% of patients were diabetic, 51% had hypertension, and other notable comorbidities included chronic pulmonary diseases (12.2%), liver disease (7.2%), and malignancies (3.4%). The most common microbiological cause was Pseudomonas aeruginosa (30%), followed by Staphylococcus aureus (10%). Surgical interventions were performed in 3.7% of cases, and cranial nerve involvement was reported in 9% of patients, primarily affecting the facial nerve (91%). Morbidity related to MOE was found to be 15.2%, and sepsis was a complication in 0.5% of cases. The results underscore the importance of addressing both comorbidities and mortality risks in managing MOE patients.

Conclusion: This review highlights a significant global mortality rate of 18% in patients with MOE, with comorbidities like diabetes and hypertension contributing to worse outcomes. Despite current treatment advancements, mortality and morbidity remain substantial, stressing the need for early diagnosis, targeted interventions, and improved management strategies to enhance patient survival and outcomes.

Background: Surgical intervention remains the primary treatment for localized renal tumors and masses, with partial nephrectomy (PN) and radical nephrectomy (RN) being the two most frequently employed procedures. The choice between these approaches is often influenced by factors such as tumor size, location, histology, and patient comorbidities. However, the decision between PN and RN remains a subject of ongoing debate, particularly as emerging evidence suggests varying outcomes based on the stage and type of renal tumors. This meta-analysis evaluates the association between renal tumor stage and subtype with the outcomes of PN and RN, focusing on renal function, cancer-specific survival, and postoperative complications.

Method: An exhaustive search was conducted across PubMed, Scopus, and Embase databases, covering the literature from their inception up to March 2023, in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Original studies comparing PN to RN in the management of renal tumors at various stages were meticulously screened, adhering to stringent inclusion and exclusion criteria. This protocol was registered on PROSPERO (CRD42023455985).

Result: Overall, 38 cohort studies were included, with a total of 144,608 patients diagnosed with renal cancer who underwent nephrectomy, 71,582 who underwent PN, and 72,671 who underwent RN. The data revealed a significant difference in cancer-specific survival between PN and RN, which was higher in the RN group (pooled HR: 1.17; 95% CI = 1.01–1.35) p < 0.001. The postoperative renal function of patients who underwent RN was worse than that of patients who underwent PN (pooled RR: 4.22; 95% CI: 1.45, 12.27, p < 0.00001). The relative risk of papillary renal cell carcinoma (RCC) was lower in patients who underwent RN as compared to PN (the pooled RR, 1.32; 95% CI = 1.02, 1.72, p < 0.001), while the relative risk of RCC collecting duct subtype was significantly lower patients who underwent PN as compared to RN (the pooled RR, 0.44 (95% CI = 0.29, 0.67) p = 0.97. Additionally, the pooled risk for patients with a Charlson Comorbidity Index score of ≥2 was lower in the PN group compared to the RN group.

Conclusion: Across various tumor stages, RN demonstrates superior cancer-specific survival, and a lower incidence of postoperative complications compared to PN. However, PN is associated with more favorable renal function preservation. These findings, in conjunction with individual patient characteristics, should be meticulously evaluated to inform the selection of the most appropriate surgical approach and guide patient counseling.

Background: Pleural diseases are common and often require drainage, with the growing use of small-bore chest drains (SBCDs) instead of larger tubes. This review aimed to examine the failure rate and complications associated with SBCD use in different pleural pathologies.

Methods: A literature search (PubMed, SCOPUS, and Google Scholar) was performed on the complications associated with SBCDs to treat pleural diseases. This review analyzed patient demographics, indications, outcomes, failure rate, and complications associated with the use of SBCDs. The systematic review was conducted using PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines.

Results: Thirty studies were included in this review with 4,973 patients. The indications for insertions of SBCDs were pleural effusion at 48.4%, pneumothorax at 30.1%, empyema or parapneumonic effusion at 11.4%, hemothorax at 6.5%, and other indications at 3.6%. The overall failure rate to achieve satisfactory drainage was 19.4%. Significant complications included iatrogenic pneumothorax at 11.9%, major hemorrhage at 1.0%, local bleeding at 0.7%, infection at 1.2%, and iatrogenic organ injury at 0.9%. Other insertional complications included tube dislodgement at 5.9%, tube blockage at 5.4%, tube kinking at 3.7%, misplacement at 3.3%, and subcutaneous hematoma at 0.5%. Most of the data published revolves around hemodynamically stable patients with SBCD insertions and is, thus, deficient regarding hemodynamically unstable patients.

Conclusion: Despite carrying notable failure rates and complications, small-bore catheters remain an acceptable option for managing selected pleural diseases.

Background: Mad honey is a unique type of honey that is contaminated with grayanotoxins. The consumption of this honey might cause poisoning, which manifests as a wide range of signs and symptoms. We report a patient with mad honey disease who presented to our Emergency Department (ED). This is the first case report of mad honey disease in Qatar.

Case presentation: A 39-year-old male Nepalese patient presented to our ED, who complained of dizziness and feeling unwell for approximately 2 hours. He was found to be hypotensive and bradycardic. The patient responded to the supportive management provided, but a few hours later, he developed hypotension, bradycardia, and first-degree atrioventricular block. Mad honey intoxication was confirmed based on the dietary history and onset of symptoms after honey consumption. Atropine and supportive treatments were continued until the patient stabilized.

Discussion: Mad honey contains grayanotoxins, which are a group of neurotoxins produced mainly by species of the Rhododendron genus within the Ericaceae family. Grayanotoxins exert their toxic effects through binding to sodium channels in cell membranes and muscarinic M2 receptors in the vagus nerve. Although mad honey poisoning is usually a benign condition, significant morbidity has been reported.

Conclusion: Although mad honey disease is rarely encountered in the Middle East, it is not unlikely to occur. Obtaining an appropriate medical and dietary history with timely recognition of the signs and symptoms of grayanotoxin poisoning could substantially improve the initiation of supportive management and minimize morbidity.

Background: Fecaloma is a mass of hardened feces impacted in the rectum and sigmoid. When the colonic mucosal wall and vasculature are compressed, stercoral colitis, a rare type of inflammatory colitis, may occur. Despite being connected to psychiatric patients and antipsychotic medications in the literature, fecaloma remains a significant, yet often overlooked, cause of morbidity and mortality in this population.

Case Presentation: A 43-year-old patient with schizophrenia being treated with aripiprazole and benztropine lost follow-up and eventually presented to the emergency department with a giant fecaloma and associated stercoral colitis. She was managed with oral and rectal laxatives and supportive therapy. Additionally, aripiprazole was discontinued.

Discussion: Antipsychotics have been associated with constipation, fecaloma, and stercoral colitis due to their anticholinergic properties. Benztropine, an antimuscarinic drug commonly used in psychiatric patients to alleviate extrapyramidal symptoms, may further decrease gastrointestinal mobility. Fecaloma and associated stercoral colitis are often diagnosed via imaging, typically a computed tomography scan of the abdomen. Management depends on the severity and generally ranges from conservative treatment to surgical options.

Conclusion: This case describes a schizophrenic patient undergoing treatment with aripiprazole and benztropine who presented with constipation and was diagnosed with a giant fecaloma complicated by stercoral colitis. The patient was managed successfully with aggressive laxatives and discontinuation of aripiprazole. Early recognition and prompt management of fecaloma are essential to mitigate associated complications. In addition, it is important to recognize risk factors for constipation and regularly review home medications, such as antipsychotics, that may cause constipation as a side effect.

Background: Cerebral venous sinus thrombosis (CVST) is an uncommon yet critical complication, especially when arising from heparin-induced thrombocytopenia (HIT). In patients with preexisting conditions such as myasthenia gravis (MG), this correlation adds further complexity to clinical management and outcomes.

Case presentation: We report a unique case of CVST induced by HIT in a patient with an established diagnosis of MG. Following plasma exchange therapy, which included heparin administration, the patient developed symptoms indicative of CVST. Diagnostic imaging confirmed thrombosis in the cerebral venous sinuses. Management involved the immediate discontinuation of heparin and the initiation of fondaparinux, leading to effective anticoagulation and clinical improvement.

Discussion: This case illustrates the rare intersection of CVST and HIT within the context of MG, underscoring the potential risks associated with heparin therapy in vulnerable patient populations. Early recognition of the signs is essential, as these conditions, in combination, demand prompt and specialized interventions to prevent serious complications.

Conclusion: The successful management of this complex case demonstrates the importance of heightened awareness and proactive strategies in patients with MG undergoing heparin therapy. This report advocates for careful monitoring and tailored treatment to mitigate risks in similarly complex clinical scenarios.

Background: Diabetic striatopathy (DS) typically presents with hemichoreoballism and contralateral striatal lesions on neuroimaging. However, cases of unilateral movement disorders with predominant ipsilateral striatal lesions are rare.

Case presentation: We present a case of DS in a 62-year-old woman from rural India with poorly controlled diabetes mellitus who developed acute-onset right hemichoreoballism. Neuroimaging revealed a predominantly right-sided striatal lesion, illustrating a clinicoradiological discordance—a mismatch between the clinical symptoms and radiological findings. Despite achieving tight glycemic control and administering neuroleptic medications, the involuntary movements demonstrated only partial improvement. Neurological changes persisted on the ipsilateral side of the affected limbs even after 1 year of follow-up. Notably, perioral dyskinesias developed during subsequent follow-up visits.

Discussion: This report highlights the clinical and neuroradiological discordance observed in DS. The potential underlying mechanisms contributing to this paradox are explored and discussed.

Conclusion: The clinical and radiological discordance in DS is a frequent yet under-reported phenomenon. However, the actual mechanistic underpinnings need to be addressed by advanced functional and structural neuroimaging.

Background: Re-expansion pulmonary edema (REPE) is traditionally associated with the resolution of pneumothorax or pleural effusion. Its occurrence after routine cardiopulmonary bypass (CPB) in cardiac surgery is rare. The incidence of REPE after treatment of pneumothorax or pleural effusion is less than 1%, but it carries a mortality rate of up to 20%.

Case Presentation: We present a case of REPE in a 64-year-old male undergoing elective coronary artery bypass grafting. Despite an uneventful surgery and standard perioperative management, the patient developed REPE, manifested with increased airway pressures, blood-tinged secretions, and compromised oxygenation post-CPB. Immediate intervention comprising mechanical ventilation adjustments, diuretics, and vasopressor support was initiated to facilitate recovery. The pulmonary edema resolved within 24 hours after the surgery, and the patient was transferred to the surgical high-dependency unit (HDU) on the third postoperative day.

Discussion: This case reports a rare occurrence of REPE following routine CPB and highlights the multifactorial pathogenesis involving reperfusion injury and altered pulmonary physiology. Possible mechanisms include reperfusion injury from free radicals, cytokine release, and increased vascular permeability. The management of REPE requires prompt recognition and treatment and involves diuretics, ventilatory adjustments, and hemodynamic monitoring.

Conclusion: REPE, though rare post-CPB, requires a high index of suspicion and prompt management to prevent adverse outcomes.

Background: Traumatic injuries to the extrahepatic bile ducts are rare, with an incidence of 0.4%–0.6% in cholecystectomy procedures among adults, particularly following the introduction of laparoscopic cholecystectomy. Among these, the presence of foreign bodies within the biliary tree is exceptionally rare, with obstructive jaundice caused by a bullet lodged in the common hepatic duct being particularly uncommon. This case report aims to share the diagnostic process and the challenges in managing such a rare condition.

Case Presentation: A 41-year-old female with a 13-year history of an accidental gunshot wound, which required an emergency laparotomy, presented to our hospital with symptoms of cholangitis. Endoscopic retrograde cholangiopancreatography was performed, revealing a bullet that caused significant dilation of the proximal bile duct. Exploratory laparoscopy, cholecystectomy, and intraoperative cholangiography confirmed the presence of the bullet. The procedure included a choledochotomy and removal of the bullet, followed by primary closure of the common bile duct using interrupted 4-0 Prolene sutures. The patient was discharged on the 11th postoperative day, and follow-up revealed complete resolution of symptoms and normal liver function.

Discussion: This case underscores the rarity and complexity of managing extrahepatic bile duct injuries caused by foreign bodies. The delayed presentation of symptoms and the unique diagnostic challenges highlight the necessity for meticulous imaging. The successful surgical intervention in this case highlights the importance of individualized treatment strategies implemented by a multidisciplinary team.

Conclusion: Managing traumatic injuries to the extrahepatic bile ducts requires careful consideration due to their rarity and complexity. The challenges in diagnosis and treatment underscore the necessity of a multidisciplinary approach.

Background: A complete heart block (CHB) entails the total loss of atrioventricular conduction and the failure to transmit any supraventricular impulses to the ventricles. To date, there have been no reports of CHB following the injection of intravenous contrast dye for computerized tomography.

Case Presentation: This case study details a patient who experienced a CHB and a syncopal episode after receiving intravenous contrast for a chest computed tomography (CT) scan. The patient was treated successfully for the anaphylactic reaction with steroids and intravenous fluid, and the heart rate improved with atropine and transcutaneous pacing.

Discussion: Contrast agents can affect cardiac conduction and endothelial integrity through their ionic strength, osmolality, and the release of histamine. These factors, combined with localized ischemia and adenosine release, may disrupt ion flow, potentially leading to transient or permanent atrioventricular block.

Conclusion: Anaphylactic reactions to CT contrast agents can lead to life-threatening cardiovascular complications, as exemplified in this case. Timely recognition and management of anaphylaxis, along with close cardiac monitoring, are crucial in such situations. Clinicians should be vigilant regarding the potential for severe cardiac manifestations in susceptible patients experiencing contrast-induced anaphylactic reactions, and they should take appropriate measures to ensure optimal care and recovery.

Background: Lung cancer is a leading cause of cancer-related mortality globally, often presenting with diverse and challenging manifestations. This case report discusses an unusual presentation of epidermal growth factor receptor (EGFR)-mutated non-small-cell lung cancer (NSCLC) initially mimicking tuberculosis (TB), complicated by pituitary involvement.

Case Presentation: A 30-year-old female presented with respiratory symptoms and systemic complaints, initially suggestive of miliary TB. Further investigations revealed metastatic lung adenocarcinoma with pituitary metastasis, causing diabetes insipidus, hyperprolactinemia, adrenal insufficiency, and hypothyroidism. Treatment with targeted therapy involving osimertinib resulted in clinical improvement.

Conclusion: This case underscores the diagnostic challenges posed by atypical presentations of lung cancer, which can masquerade as infectious diseases like TB. The presence of pituitary metastasis further complicates the clinical picture, emphasizing the importance of considering rare metastatic sites in the differential diagnosis of lung adenocarcinoma. Timely recognition and appropriate management are crucial for optimizing outcomes in such complex cases, highlighting the need for a multidisciplinary approach in oncological and endocrine care.

Introduction: Systemic lupus erythematosus (SLE) is a systemic autoimmune disease characterized by a dysregulated immune response against self-antigen, leading to multi-organ involvement. Myositis, as an initial manifestation of SLE, is a rare clinical entity, particularly in newly diagnosed patients.

Case Presentation: A 27-year-old male presented with massive head and neck swelling, initially suspected to be superior vena cava syndrome (SVCS). Other symptoms included non-scarring alopecia, prolonged fever, oral ulcers, a history of hyperpigmented skin lesions, and progressive lower extremity weakness with edema. Hematological findings revealed persistent pancytopenia (anemia, leukopenia, and thrombocytopenia). Laboratory investigations demonstrated elevated muscle injury markers, including aspartate aminotransferase predominance and elevated creatine kinase. Immunological analysis showed a negative antinuclear antibody by indirect immunofluorescence, high anti-dsDNA titers, and normal complement levels. Bone marrow biopsy revealed trilineage dysplasia with macrophage activation, suggesting underlying hematologic involvement. Contrast-enhanced head and neck computed tomography ruled out SVCS, showing only diffuse muscle and subcutaneous edema. Based on the constellation of clinical, hematological, and imaging findings, the patient was diagnosed with myositis-associated SLE. The therapeutic approach included total plasma exchange (TPE), high-dose corticosteroid pulse therapy, and immunosuppressive induction therapy. Within 1 month of hospitalization, the patient demonstrated significant clinical and laboratory improvement and was subsequently transitioned to maintenance therapy with hydroxychloroquine (200 mg once daily), methylprednisolone (8 mg daily in a tapering regimen), and mycophenolate mofetil (500 mg twice daily). The patient achieved a lupus low disease activity state at follow-up.

Discussion: This case represents a unique presentation of head and neck myositis in a newly diagnosed SLE patient, a manifestation not previously described in the literature. While orbital myositis in SLE has been reported, extensive myositis involving the head and neck as an initial SLE manifestation remains undocumented. Combining TPE, high-dose corticosteroids, and immunosuppressants was critical in disease control. Early recognition and aggressive immunomodulatory therapy are essential in managing such rare and severe SLE presentations.

Conclusion: This case highlights an uncommon initial manifestation of SLE, emphasizing the importance of early clinical suspicion, comprehensive immunological and hematological evaluation, and prompt intervention. A multimodal therapeutic approach, including steroid pulse therapy, induction immunosuppression, and TPE, can lead to favorable clinical outcomes in severe and atypical SLE presentations.