Qatar Medical Journal - Current Issue

Introduction: Language impairment can present as a symptom of both psychiatric or a neurological condition, so making an accurate diagnosis is essential for appropriate management. While primary psychiatric disorders such as schizophrenia may include thought disorganization and speech abnormalities, true language dysfunction is typically associated with neurological pathology, such as stroke, neurodegenerative diseases, or traumatic brain injury. In cases where patients present with language impairment but lack a clear medical and psychiatric history, distinguishing between these possibilities becomes particularly challenging. A comprehensive assessment, including a neurological examination with potential imaging and a psychiatric evaluation, is crucial in these scenarios. This challenge is even more pronounced in populations such as lower-skilled migrant workers, where language barriers and a lack of collateral information further complicate the diagnostic process.

Case Presentation: We report on a case of a patient presenting with significant language impairment who was initially misdiagnosed with a psychotic illness. The patient exhibited speech disturbances and communication difficulties that were initially interpreted as signs of disorganized thought processes, a hallmark of psychosis. However, further evaluation, including neuroimaging, revealed significant atrophy in the bilateral anterior temporal lobes, confirming a neurological basis for the symptoms. The absence of a prior medical history and limited collateral information contributed to the initial misdiagnosis.

Conclusion: This case highlights the critical need for a thorough psychiatric and neurological workup in patients presenting with language impairment and an unclear history. Misdiagnosis can lead to inappropriate treatment and worsen patient outcomes. A careful evaluation, including neuroimaging and linguistic assessment, is essential in distinguishing between psychiatric and neurological etiologies. Moreover, addressing barriers related to language and medical history is vital to improving diagnostic accuracy, particularly in immigrant populations.

Background: Dexmedetomidine is a highly selective α2-adrenergic agonist with sedo-analgesic properties. It has been approved by the United States Food and Drug Administration (FDA) for sedation of critically ill patients, facilitation of awake procedures, and management of patient agitation. However, its use has been occasionally associated with adverse effects like bradycardia, hypotension, and asystole. The risk of these effects, particularly cardiac arrest, is increased in the elderly, patients with multiple comorbidities, and administration of higher doses of the drug (especially loading doses). However, perioperative pericardiac arrest with only low-dose dexmedetomidine infusion, in a young healthy male, has not been previously reported.

Case Presentation: We report a 33-year-old male, ASA 1 E, who underwent open reduction and internal fixation of a left ankle fracture under spinal anesthesia. He was sedated intraoperatively with intravenous dexmedetomidine, infused at 0.2 μg/kg/h, without a loading dose. Approximately 90 minutes into the procedure, he had severe bradycardia and hypotension, leading to a peri-arrest situation. He was successfully revived with intravenous atropine and ephedrine and completed the surgery uneventfully.

Conclusion: We opine that the use of dexmedetomidine as a sedative agent in patients under spinal anesthesia requires heightened caution due to the risk of major adverse cardiac events. Our case exemplifies that this risk persists even in healthy young patients, at low drug infusion rates, and even after avoiding a loading dose.

Background: Varicella zoster virus (VZV) reactivation can occur without the characteristic rash, a condition known as zoster sine herpete (ZSH). This case report highlights a rare presentation of VZV reactivation.

Case presentation: We present the case of a 40-year-old immunocompetent woman with a five-day history of headache, followed by neuropathic dermatomal pain localized to the left C2–C3 dermatomes. Cerebrospinal fluid analysis demonstrated a positive polymerase chain reaction (PCR) for VZV, confirming a diagnosis of ZSH complicated by VZV meningitis.

Discussion: The patient’s condition necessitated intravenous acyclovir therapy for 21 days. VZV meningitis can lead to severe outcomes, highlighting the importance of prompt diagnosis and timely treatment to prevent complications. The absence of a rash in ZSH necessitates heightened clinical suspicion to avoid potentially life-threatening consequences of VZV reactivation.

Conclusion: Early recognition and prompt intervention are crucial for managing ZSH and preventing severe complications such as VZV meningitis, highlighting the importance of clinical awareness of atypical presentations of VZV reactivation among healthcare providers.

Background: Dengue is the most common arthropod-borne viral illness in humans and is prevalent in tropical and subtropical regions worldwide. Nearly half of the world’s population living in these endemic areas is at risk of infection.

Case presentation: A 42-year-old Bangladeshi male, previously healthy and working as a laborer, was admitted to Hazm Mebaireek General Hospital—a Qatar government hospital serving mainly laborer populations—with a 3-day history of abdominal pain, fever, and intermittent vomiting. He had no recent history of travel to Bangladesh before this incident. Viral studies were positive for dengue virus immunoglobulin G and immunoglobulin M. Magnetic resonance imaging revealed a posterior extradural collection extending from cervical (C) 3 to dorsal (T) 7, resulting in compression of the posterior aspect of the thecal sac and causing it to appear off-center within the spinal canal. The findings suggested that the collection was most likely infective in origin. He underwent a right-sided C7 hemilaminectomy and evacuation of an epidural hematoma at Hamad General Hospital, Qatar. Postoperatively, he improved significantly. He was subsequently transferred to the Qatar Rehabilitation Institute for an active rehabilitation program and was discharged upon completion of rehabilitation.

Discussion: Dengue is prevalent in subtropical regions and South America, accounting for nearly 75% of global cases. Qatar is a non-endemic zone for dengue fever. Spinal cord epidural hematoma due to dengue fever is extremely rare, with only five cases reported to date according to our literature review. Our case will be the 22nd reported instance—and the sixth among similar series—of spontaneous spinal hemorrhage due to dengue in the literature, and the first reported from a non-endemic zone. The neurological manifestation in our case was hemiplegia. Among the five previously reported cases, two presented with quadriplegia and three with paraplegia.

Conclusion: Gulf countries are at particularly high risk among non-endemic regions due to the large number of expatriates returning from endemic areas. This case indicates that atypical presentations of dengue can also occur in non-endemic regions. We believe that early screening for tropical fevers in suspected cases can facilitate prompt diagnosis and management of dengue fever. To our knowledge, this is the first reported case of spinal hemorrhage due to dengue fever from a non-endemic zone. Moreover, our patient presented with hemiparesis, whereas the four previously reported cases manifested as either quadriplegia or paraplegia.

Background: Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening hyperinflammatory syndrome characterized by excessive immune activation. Children with Down syndrome (DS) (trisomy 21) are at increased risk of severe infections and immune dysregulation. Although viral infections are known triggers of secondary HLH, H1N1 influenza is an uncommon cause in this population.

Case presentation: We report a 1.8-month-old male infant with DS and multiple comorbidities—including gastroesophageal reflux disease (GERD), recurrent aspiration pneumonia, and seizures—who presented with fever, hypoxemia, and splenomegaly. Laboratory investigations revealed cytopenias, hyperferritinemia (>1,650 ng/mL), and hypofibrinogenemia, fulfilling five of the HLH-2004 diagnostic criteria. H1N1 influenza was confirmed as the infectious trigger. The patient was treated with standard-dose dexamethasone and etoposide, along with oseltamivir. Despite concerns about treatment-related toxicity in DS, he tolerated the regimen without hematologic or infectious complications. He achieved clinical remission with normalization of inflammatory markers and hematologic parameters. At discharge and at three-month follow-up, he remained well with no recurrence or neurological sequelae.

Discussion: This case highlights the diagnostic and therapeutic challenges of managing HLH in children with DS. The use of conventional HLH therapy, including etoposide, was effective and well-tolerated despite theoretical concerns in this population. Although central nervous system symptoms were present, they resolved with treatment. H1N1 influenza should be considered a potential viral trigger in immunocompromised children presenting with HLH-like features.

Conclusion: H1N1 influenza-induced HLH is exceptionally rare in infants with DS. The positive outcome in this case supports the safe use of standard HLH protocols in this vulnerable population and highlights the importance of early diagnosis and multidisciplinary management to optimize outcomes.