Qatar Medical Journal - Volume 2026, Issue 1

Introduction: The boarding of patients with psychiatric illnesses in the Emergency Department (ED) has become a prevalent issue across the world, posing significant challenges for healthcare providers.

Objectives: This study aimed to assess the perceived competency and attitude of emergency nurses toward the care of patients boarding with psychiatric illnesses.

Methodology: This was a prospective cross-sectional research study used to recruit emergency nurses working in four selected facilities under the organization. The study utilized a validated questionnaire, the Opening Minds Scale for Health Care Providers (OMS-HC-15) and Behavioral Health Care Competency (BHCC) to collect the information from the participants through an online survey using a total enumerative sampling method. Frequency and percentage were used to find the demographic characteristics of the participants. ANOVA and t-tests were used to find out the association between the attitudes, competencies, and demographic profile of the participants.

Results: Three hundred and ten completed responses from the participants were used for analysis. Most participants were in the 31 to 40 years age group (72.26%; n = 224), with a mean age of 42 years, which ranged from 26 to 56 years. Males (n = 183) participated more compared to females (n = 127), and 85.16% (n = 264) of them have Bachelor’s degrees in nursing. 40% (n = 124) of the participants have more than 10 years of experience in ED. The mean percentage scores of attitude and competency domains were −14.16 ± 36.26 and 35.07 ± 25.73, respectively. The competency domain showed a statistically significant correlation with the participants’ age (P = 0.038) and their facility (P = 0.014). In contrast, attitude did not exhibit statistical significance with any demographic variables.

Conclusion: The emerging data from the current study stated that the attitudes of ED nurses were predominantly positive; however, their perceived competency was falling below average. This highlights the need to improve their competency to strengthen the current practice, the quality of care, and the overall experiences of psychiatric patients in the ED.

Background and objective: CT-guided cryoablation (CRA) has emerged as a safe and effective minimally invasive treatment for renal cell carcinoma (RCC), though outcomes can vary. The mRENAL score may help to predict clinical outcomes. The main objective of this study was to evaluate the correlation between mRENAL score and clinical outcomes in RCC cases treated by CT-CRA.

Methodology: This was an observational, retrospective, single-center study that included CT-CRA procedures performed on RCCs between 2017 and 2023. Tumors were classified into three categories based on the mRENAL score: low, intermediate, and high risk. We employed the Firth logistic regression for multivariate analysis due to the small sample size and rare outcome events.

Results: Our data included 53 cases, with a mean age of 53 ± 12 years. Technical success was achieved in all cases. Four cases had disease recurrence at the site of previously treated RCC (4/42, 9.5%), as 11 cases lost follow-up imaging. The Firth logistic regression analysis revealed that increasing mRENAL score was associated with a higher risk of recurrence (adjusted odds ratio = 0.42 [95% CI, 0.19–0.95]; P = 0.038). This trend towards statistical significance implies that for every 1-point increase in mRENAL score, the odds of clinical success decrease by at least 5% with over 95% confidence. No procedure-related mortality was observed.

Conclusion: Our analysis demonstrates that the mRENAL score may help predict clinical outcomes, with lower mRENAL scores associated with higher clinical success rates following CT-CRA of RCC.

Background: Neoadjuvant chemotherapy (NACT) is used in breast cancer (BC) to downsize and downstage the tumor before surgery. Different studies were conducted looking into the alterations in the immunohistochemistry after NACT, which may alter the adjuvant treatment. Our study aimed to assess the changes in immunohistochemistry biomarker status (estrogen receptor [ER], progesterone receptor [PR], and human epidermal growth factor receptor 2 [HER2]) in BC cells after administration of NACT at a single institution in Oman.

Methods: We conducted a retrospective cross-sectional study on patients with BC with residual disease post-NACT in a single institution and studied immunohistochemistry status changes before and after NACT. We used the McNemar test to evaluate the receptor changes, and logistic regression to assess the effect of risk factors on receptor status change.

Results: All biomarkers changed after NACT, with a tendency for BC cells to lose PR and HER2 expression and gain ER expression. The immunohistochemistry changes were 36/114 (31.6%) in PR, 7/114 (6.1%) in ER, and 11/114 (9.6%) in HER2. BC subtypes changed in 4/114 (3.5%) of HER2+ve, 10/114 (8.8%) of hormone positive (ER or PR) with HER2 overexpression (HER2+ve/HR+ve), 3/114 (2.6%) in hormone positive with HER2 negative (HR+ve), and 3/114 (2.6%) triple-negative BCs. These changes resulted in adjuvant treatment adjustments in 9/110 (8.18%) patients with residual disease.

Conclusion: Changes in the expression of all immunohistochemistry biomarkers and BC subtypes occurred after NACT, which led to changes in adjuvant treatment in specific cases.

Background: Vaccine-preventable diseases (VPDs) remain a public-health concern in Qatar despite high immunization coverage. Frequent population movement and incomplete vaccination records may lead to susceptibility clusters and under-reporting. These dynamics underline the need for sustained surveillance and targeted immunization strategies. This study aims to assess the influence of geographical variation and age-specific demographics on VPD incidence among the Primary Health Care Corporation (PHCC)-registered population in Qatar to inform immunization planning and address emerging gaps.

Methods: A retrospective analysis of Qatar’s Ministry of Public Health surveillance data (2021–2024), supplemented by PHCC medical records, examined annual incidence rates of VPDs by age group and region. Cases included acute flaccid paralysis, chickenpox, mumps, measles, pertussis, rotavirus, and meningitis due to viral, Haemophilus influenzae, Streptococcus pneumoniae, Neisseria meningitidis, and bacterial non-meningococcal pathogens.

Results: Between 2021 and 2024, 5136 confirmed VPD cases were reported among PHCC-registered individuals. Chickenpox was most frequent, peaking in 2023 (1398 cases). Incidence was highest in children under 5 years old, particularly infants, for chickenpox (145.75/100,000), measles (66.35), pertussis (59.95), and rotavirus (47.61). Viral meningitis was concentrated in infants, with the Western region recording the highest rate (70.02). Regionally, chickenpox burden was greatest in the Central region, while pertussis, rotavirus, and measles rates were highest in the Western region. No statistically significant differences were observed between regions or across study years (P > 0.05 for all comparisons).

Conclusion: Age-specific disparities in VPD incidence were noted in Qatar, with the highest burden among children under 5 years and in the Western region. Chickenpox was the most reported disease, followed by pertussis, rotavirus, and viral meningitis. No statistically significant differences were observed between regions, suggesting equitable immunization delivery across PHCC. These findings highlight the need to sustain high vaccination coverage, enhance parent-focused health education, strengthen surveillance to detect immunity gaps, and improve data linkage across PHCC, private providers, and national surveillance systems.

Background: Assessing the quality of recovery (QOR) after open gynaecological surgery done under general anaesthesia (GA) is one of the methods to evaluate anaesthesia outcomes effectively. GA can be administered as full inhalation anaesthesia (FIA) and/or total intravenous anaesthesia (TIVA). Studies have not compared QOR between TIVA and FIA in this cohort. Our study aims to compare the effect of TIVA and FIA on postoperative recovery of patients assessed by the Quality of Recovery-40 (QOR-40) questionnaire.

Methods: One hundred and eight consenting adult patients posted for open gynaecological surgeries under GA were randomly allocated to Sevoflurane-based full inhalation anaesthesia (Group FIA) or propofol-based TIVA (Group TIVA). The primary outcome was comparing the QOR-40 score on the first postoperative day (POD1). Comparing QOR-40 on POD2, extubation time, and Modified Observer’s Assessment of Alertness/Sedation Scale (MOAA/S) score after extubation were the secondary outcomes. Epidural analgesia was provided throughout the study period in both groups.

Results: The mean QOR-40 score in group FIA was not significantly different from that in group TIVA (171.44 ± 7.43 vs. 171.37 ± 7.48; P = 0.951). However, within the group, there was a significant reduction in scores in POD1 (P < 0.001) and POD2 (P < 0.001) from pre-operative values. There was no significant difference in extubation time (P = 0.207) and MOAA/S score (P = 0.548) between the groups.

Conclusion: Our study found no significant difference in QOR-40 score, extubation time, and MOAA/S score between group FIA and TIVA.

Background: Alcohol consumption is associated with significant morbidities such as liver disease, cardiovascular issues, and mental health disorders like depression and anxiety. Addressing acute alcohol withdrawal syndrome (AWS) effectively is essential to improving the health outcomes of individuals with alcohol use disorders. This study aims to evaluate AWS management practices and outcomes, with a focus on symptom severity, treatment protocols, and factors associated with prolonged or complicated hospital stays.

Methods: This retrospective cohort study analyzed medical records of patients admitted to Hazm Mebaireek General Hospital (HMGH) with AWS between November 1, 2018, and October 31, 2021. Parameters assessed included demographic details, symptom severity using scales like Cushman’s and SOFA, benzodiazepine treatment protocols, and outcomes such as length of stay, ICU admissions, and mortality.

Results: A total of 98 male patients were included, with a mean age of 39.9 ± 9.7 years. Among these, 51% were Indian nationals, followed by Nepalese (33%). Symptoms ranged from nausea (33%) to agitation (36%) and tremors (67%). Severity levels of AWS varied, with 59% experiencing mild symptoms, 34% moderate, and 7% severe. Fixed-dose and symptom-triggered benzodiazepine regimens were applied inconsistently, often deviating from recommended guidelines. Complications included seizures in 14% of cases and ICU admissions in 4%. The average hospital stay was 4.7 ± 5.1 days.

Conclusion: AWS predominantly affects young males, with a significant burden on healthcare resources. Treatment strategies often diverged from international guidelines, emphasizing the need for standardized protocols to improve care quality and reduce variability in outcomes.

Background: Malignant mesothelioma (MM) is a potentially fatal cancer that originates from the mesothelial surfaces, predominantly the pleura. Asbestos is the principal risk factor with a long latency period between exposure and disease development. The objective of this study was to investigate the clinical and epidemiological characteristics of MM in the State of Qatar.

Methodology: This was a retrospective cohort study of all MM cases diagnosed in the State of Qatar during the period from January 1, 2015, to December 31, 2023. MM cases were identified from the Qatari National Cancer Registry Database and the Hamad Medical Corporation (HMC) Histopathology Database. Demographic, clinical, laboratory, radiologic, and survival data were collected from these two databases.

Results: Among the total 22 MM cases diagnosed during the study period, migrant Egyptians constituted 15/22 (68.2%). The mean age for the study population was 57.9 ± 9.2 years with an age-standardized incidence rate of 24.1 cases per 1,000,000 individuals per year. The epithelioid histologic type was the predominant type (16/19; 84.2%), and most patients (13/14; 92.9%) were diagnosed at an advanced disease stage. The median overall survival (OS) was 16 months. The 1-year OS rate was 60.67%, dropping to 20.22% over 3 years. Though the differences were not statistically significant, patients with epithelioid histology and those with left-sided tumors experienced better OS outcomes.

Conclusion: MM is predominantly a cancer of Egyptian migrants in the State of Qatar, with a comparable incidence to the international rates. Epithelioid histologic type is the most common type in the State of Qatar, and the majority of patients are diagnosed at an advanced disease stage. Despite a better OS rate compared to other countries, the prognosis of MM remains grave.

Background: Polypharmacy and potentially inappropriate medications (PIMs) exposure are common in older adults, especially in emergency departments (EDs) with rapid decisions and incomplete histories. Pharmacist-led medication reconciliation improves safety but is rarely implemented in Iran.

Objective: This study aimed to evaluate the prevalence and patterns of PIM use, medication regimen complexity, and associated factors among elderly patients admitted to the ED.

Methodology: This cross-sectional study of patients aged 65+ years at Alzahra Hospital (October 2023–March 2024) involved medication reconciliation by pharmacy students under supervision. PIMs were identified using the 2023 American Geriatrics Society (AGS) Beers Criteria. Medication complexity and comorbidities were assessed via Medication Regimen Complexity Index (MRCI) and Charlson Comorbidity Index (CCI), with results analyzed through regression.

Results: A total of 200 patients were included (mean age 78.1 ± 7.8 years; males: 109, 54.5%). Polypharmacy was observed in 104 patients (52%). The mean MRCI was 23.8 ± 13.5, and the mean CCI was 2.3 ± 1.6. PIM exposure was identified in 75 patients (37.5%), with 221 PIM prescriptions. The most frequent PIM classes were benzodiazepines (49/221, 22.2%), atypical antipsychotics (28/221, 12.7%), opioids (24/221, 10.9%), and Non-Steroidal Anti–Inflammatory Drugs (NSAIDs: 18/221, 8.1%). Clinically significant drug–drug interactions occurred in 30 patients (15%). Female sex, mild comorbidity (CCI, 1–2), and higher MRCI independently predicted PIM use.

Conclusions: PIM exposure was frequent among elderly ED patients. Pharmacist-led medication reconciliation effectively identified inappropriate prescribing and complex regimens, supporting the integration of clinical pharmacists into emergency care to improve geriatric medication safety.

Background: Systemic lupus erythematosus (SLE) is a complex autoimmune disease with heterogeneous clinical presentations influenced by ethnicity, geography, and healthcare practices. This audit evaluated adherence to key quality indicators for SLE management at Hamad General Hospital (HGH), a major public tertiary care center in Doha, Qatar, in line with international standards.

Methods: A retrospective cross-sectional audit was conducted between March and July 2024 involving 61 patients with SLE attending the rheumatology clinic at HGH. This audit assessed adherence to four selected key quality indicators: hydroxychloroquine (HCQ) use, annual proteinuria screening, annual ophthalmologic screening for HCQ-related retinopathy, and medication reconciliation documentation during the most recent clinic visit.

Results: All patients were initiated on HCQ, with 11.5% discontinuing it due to adverse effects. Annual proteinuria screening was completed in 95% of patients. Ophthalmologic screening for HCQ-related retinopathy was documented in 65%, and medication reconciliation was completed in 72% of cases. The cohort represented a total of 21 nationalities, including Qataris who accounted for 31%–a proportion higher than their estimated 11.6% representation in Qatar’s national population.

Conclusion: While adherence to HCQ initiation and renal monitoring met international benchmarks, ophthalmologic screening and medication reconciliation rates were suboptimal and required improvement. Targeted system-level and educational interventions are planned to enhance adherence to these standards. Re-audit following implementation will be essential to assess progress and to sustain the quality of care.

Background: Atrial fibrillation (AF) is a common arrhythmia linked to thromboembolic risks. Rivaroxaban, a direct oral anticoagulant, prevents strokes in non-valvular AF (NVAF) patients. However, the role of genetics in its pharmacokinetics and outcomes remains unclear.

Aim of study: To explore the link between the ABCB1 (rs4148738 C>T) polymorphism, rivaroxaban steady-state plasma levels, and the occurrence of bleeding events in AF patients.

Patients and methods: This cross-sectional study examines patients with AF treated with rivaroxaban anticoagulation from September 2024 to March 2025. We gathered clinical data covering demographics, comorbidities, and treatment adherence. Biochemical tests assessed renal function (serum creatinine and urea), and the steady-state plasma concentrations of rivaroxaban were determined via high-performance liquid chromatography. Genotyping was conducted using allele-specific polymerase chain reaction.

Results: The study enrolled 100 participants (45 males, 55 females), most aged >46 years, with an obesity prevalence of 52%. The genotype distribution was noted as 26% CC, 39% CT, and 35% TT. Plasma levels of rivaroxaban were significantly lower in homozygous mutants (TT) compared to wild-type genotypes (P = 0.001). The rs4148738 polymorphism was associated with bleeding events, all of which occurred in CT carriers. This observation should be considered preliminary due to the limited sample size.

Conclusion: The ABCB1 rs4148738 polymorphism influences rivaroxaban plasma levels in NVAF patients and shows a potential link to bleeding risk.

Background: Skin closure techniques in inguinal hernia surgery significantly influence postoperative outcomes, including pain, healing, scar formation, and patient satisfaction. The aim of this study is to evaluate the efficacy of N-butyl-2-cyanoacrylate tissue adhesive as an alternative to conventional sutures for skin closure in inguinal hernia surgeries.

Methods: A prospective cross-sectional study was conducted at a tertiary care center from November 2023 to October 2025. Seventy patients aged 18–60 years undergoing inguinal hernia repair were randomly assigned to two groups: Group 1 (sutures) and Group 2 (tissue adhesive). Exclusion criteria included recurrent or strangulated hernia, allergies to cyanoacrylate/formaldehyde, and immunocompromised states. Outcomes assessed included pain (VAS), wound healing (Hollander score), scar quality (Vancouver Scar Scale and Visual Analogue Scar Scale), complications, and satisfaction scores.

Results: Group 2 showed significantly lower pain scores at early postoperative intervals (p < 0.05), shorter wound closure time (8.8 ± 1.4 min vs. 11.7 ± 2.6 min; p = 0.000), and reduced hospital stay (1.9 ± 0.8 days vs. 3.5 ± 1.6 days; p = 0.000). No infections were reported in either group. Chronic pain at 30 days was less frequent in Group 2 (p = 0.046). Wound healing and scar scores favored Group 2 on days 7 and 30 (p < 0.05). Patient satisfaction was higher in Group 2 across all follow-up visits, while surgeons preferred sutures (p < 0.05).

Conclusion:N-Butyl-2-cyanoacrylate tissue adhesive offers superior early postoperative outcomes and higher patient satisfaction compared to sutures, although surgeons reported greater satisfaction with traditional methods. Tissue adhesive is a viable alternative for skin closure in inguinal hernia surgeries.

Background: Acute respiratory distress syndrome (ARDS) remains a leading cause of mortality among critically ill patients with COVID-19. Inhaled nitric oxide (iNO), a selective pulmonary vasodilator, is often used as rescue therapy to improve oxygenation; however, its impact on survival remains uncertain.

Objective: To evaluate the clinical outcomes of iNO therapy in patients with COVID-19-related ARDS and to stratify patients into Early, Delayed, and Non-Responder groups based on the timing of their oxygenation response.

Methods: A retrospective cohort study of 99 patients with COVID-19-related ARDS who received iNO was conducted. Patients were categorized as:

Early Responders: ≥20% improvement in the PaO2/FiO2 ratio within 8 h;

Delayed Responders: ≥20% improvement in the PaO2/FiO2 ratio between 8 and 24 h;

Non-Responders: <20% improvement in the PaO2/FiO2 ratio within 24 h, including those who showed no improvement in their PaO2/FiO2 ratio within 24 h of iNO initiation.

Baseline demographics, comorbidities, and outcomes, including duration of mechanical ventilation, ICU and hospital length of stay, and mortality, were compared.

Results: Early and Delayed Responders showed significant improvement in oxygenation (mean PaO2/FiO2: 137.3 vs. 126.9 vs. 106.4; p = 0.004), with mean percentage increases of 65.3%, 56.6%, and 8.2%, respectively (p < 0.001). However, this did not translate into differences in ICU mortality (64.8%, 62.5%, and 71.4%, respectively; p = 0.81) or other hospital outcomes. Rates of acute kidney injury (AKI), methemoglobinemia, and other complications were comparable among the groups.

Conclusion: iNO improved oxygenation in a subset of patients with COVID-19-related ARDS but did not reduce mortality. Stratification by timing of response highlights patient heterogeneity and supports response-guided, time-limited use of iNO in critical care.

Background and objective: The conventional diagnostic pathway for pleural malignancy involves pleural aspiration, often followed by tissue biopsy. However, pleural aspiration has limited sensitivity, which can potentially delay a definitive diagnosis. The objective of this study was to develop and externally validate a predictive model using clinical data to identify patients who could safely bypass pleural aspiration and proceed directly to tissue biopsy.

Methods: This was a retrospective cohort study of patients presenting to an acute hospital in the UK with suspected pleural malignancy between 2016 and 2025 (n = 646). A Random Forest classifier was trained on this dataset, and its performance was evaluated using an independent external validation cohort from another acute hospital in the UK (n = 32). Model performance was assessed using standard metrics, including accuracy, precision, recall, F1-score, and the area under the receiver operating characteristic curve (ROC-AUC).

Results: The model demonstrated robust performance in the internal dataset and maintained its predictive strength during external validation (AUC: 0.86 vs. 0.83; precision 87% vs. 85%; recall 79% vs. 75%). Among the variables, computed tomography findings were the most influential predictor, as quantified by Gini importance. A simplified scoring system was subsequently derived for potential bedside clinical application.

Conclusion: This externally validated model provides a valuable decision-support tool for clinicians, facilitating earlier tissue diagnosis in patients with suspected pleural malignancy. By potentially avoiding non-diagnostic aspiration, the model can streamline the diagnostic pathway and expedite patient care. Successful external validation enhances confidence in the model’s generalizability and supports its potential for implementation into routine clinical practice.

Background: Colorectal cancer (CRC) is the third most common malignancy worldwide and accounts for 9.4% of all cancer-related deaths, making it the second leading cause of cancer mortality. Approximately 70% of patients develop metastatic disease, most commonly to the liver and lungs. Acral metastasis, particularly to the digits, is extremely rare and usually indicates advanced disease with a poor prognosis.

Case presentation: We report a rare case of digital acrometastasis from colorectal adenocarcinoma in a 55-year-old male. The patient presented with a painful lesion on his right index finger, characterized by discoloration, a wound cavity, and granulation tissue at the fingertip. The patient had a prior history of treated colon cancer and was receiving immunotherapy. He underwent wedge excision and nail avulsion of the affected finger. Histopathological examination confirmed metastatic adenocarcinoma with an immunohistochemical profile consistent with colorectal origin. The patient was referred to the National Center for Cancer Care and Research (NCCCR); however, no follow-up information was available, as he did not return for further evaluation.

Discussion: Bone metastasis from CRC is uncommon, and acrometastasis to the digits occurs in only 0.007–0.2% of cases. The differential diagnosis of digital lesions can be challenging and should include both benign and malignant conditions. Immunohistochemical staining is crucial for diagnosis, and with metastatic CRC typically expressing cytokeratin 20 (CK20) and caudal type homeobox (CDX2), it helps distinguish it from primary digital adenocarcinomas. Clinicians should consider acrometastasis in patients with a history of CRC who present with unexplained digital lesions.

Conclusion: This case underscores the rare potential of CRC to metastasize to acral regions, including the distal phalanges. Clinicians should maintain a high index of suspicion for metastatic disease when evaluating digital lesions in patients with a history of malignancy, as timely diagnosis and management are essential for optimizing patient outcomes.

Introduction: Urethral stricture disease is a complex and debilitating condition that significantly impairs urinary function and quality of life. Urethroplasty remains the gold-standard treatment, especially for complex, long-segment, or recurrent strictures. However, performing urethroplasty in patients with penile prostheses presents unique surgical challenges due to the associated anatomical and vascular considerations.

Case presentation: We report the case of a male patient with a history of penile prosthesis implantation nine years earlier who presented with a recurrent bulbar urethral stricture. The patient underwent excision and primary anastomosis (EPA) urethroplasty. Postoperatively, he developed significant urinary leakage at the anastomotic site, which was confirmed by pericatheter urethrogram, and urine culture grew extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli. The condition was managed conservatively with intravenous antibiotics and suprapubic catheter placement, resulting in resolution of the leakage and preservation of prosthesis function.

Discussion: This case highlights the interplay between urethral vascular compromise and the presence of a penile prosthesis, both of which can increase the risk of complications following urethroplasty. Infection, impaired healing, and altered anatomy contribute to the complexity of surgical management. Although the urethral stricture was amenable to EPA, the healing process was likely adversely affected by local infection and compromised blood supply.

Conclusion: Urethroplasty in patients with a penile prosthesis requires a tailored approach that accounts for altered anatomy and vascularity. In this case, the EPA was complicated by infection and urine leakage; however, conservative management resulted in successful healing, restoration of urinary flow, and preservation of prosthesis function. This case highlights the importance of careful surgical planning and flexible postoperative care.

Background: Acute asthma exacerbations commonly lead to hyperventilation-induced hypocapnia (low arterial CO2 levels). While mild hypocapnia is frequent, extreme hypocapnia (PaCO2 ≤10 mmHg) causing coma is rare. This case highlights a life-threatening instance of severe hypocapnia in an asthma patient, complicated by anxiety-related hyperventilation and management challenges related to oxygen therapy.

Case presentation: A 43-year-old man with a history of bronchial asthma presented to the emergency department with flu-like symptoms and acute shortness of breath. On arrival, he was normoxic, but he subsequently developed marked hyperventilation accompanied by carpopedal spasm and a state of unresponsiveness. Arterial blood gas analysis, while on supplemental oxygen, revealed profound respiratory alkalosis, with a pH of 7.75, PaCO2 of 10 mmHg, and PaO2 of 237 mmHg. Management consisted of cautious oxygen titration, controlled rebreathing to gradually restore carbon dioxide levels, light sedation to alleviate hyperventilation, and correction of electrolyte imbalances. Neuroimaging excluded intracranial pathology. The patient’s neurological status improved within hours, leading to complete recovery without the need for invasive mechanical ventilation.

Discussion: Asthma exacerbations complicated by severe hypocapnia present a unique and often underrecognized therapeutic dilemma. Although oxygen is essential to prevent hypoxemia, excessive administration may further lower PaCO2, exacerbate cerebral vasoconstriction, and impair perfusion. Anxiety-related hyperventilation can further amplify these effects, potentially leading to transient cerebral dysfunction. Prompt recognition of extreme hypocapnia, careful modulation of oxygen delivery, and physiologically guided ventilation are essential to restore cerebral and systemic homeostasis.

Conclusion: This case emphasizes the need to recognize extreme hypocapnia as a potential cause of coma in asthma exacerbations, especially when anxiety-driven hyperventilation is involved. With timely supportive care and careful ventilatory management, balancing oxygen therapy and CO2 control, full neurological recovery and clinical stability were achieved.

Introduction: Tuberculosis (TB) involving the central nervous system (CNS) can present as tuberculoma and may mimic neoplasms or vascular lesions, particularly when the brainstem is involved. Early recognition is critical in endemic settings such as India.

Case presentation: A previously healthy female in late adolescence presented with a one-month history of headache followed by progressive left-sided weakness and multiple cranial nerve deficits, producing a crossed brainstem syndrome. Magnetic resonance imaging (MRI) of the brain revealed conglomerated ring-enhancing lesions in the midbrain and pons, accompanied by surrounding edema. Magnetic resonance spectroscopy (MRS) demonstrated a lipid–lactate peak. Cerebrospinal fluid (CSF) analysis and systemic laboratory investigations were within normal limits. Empirical anti-tubercular therapy (ATT) with adjunctive corticosteroids was initiated, with clinical improvement noted within two weeks and continued gains on follow-up.

Discussion: Brainstem tuberculoma can closely mimic brainstem stroke and other mass lesions. In endemic regions, characteristic MRI/MRS findings should prompt consideration of tuberculoma even when CSF findings are normal. Early treatment may prevent the need for invasive diagnostic procedures and improve outcomes.

Conclusion: Brainstem tuberculoma should be considered an important differential diagnosis in young patients presenting with crossed brainstem signs in TB-endemic regions. A combination of characteristic imaging findings and high clinical suspicion can support the early initiation of ATT with adjunctive corticosteroids, which, in this case, was associated with prompt and favorable neurological recovery.