Qatar Medical Journal - Volume 2022, Issue 3

Since the beginning of the COVID-19 pandemic, several infected patients have suffered from unusual and severe complications. Among these rare complications, pneumothorax and pneumomediastinum have attracted clinical attention. Such complications might be challenging to diagnose immediately because of the atypical presentation in some cases. Accurate diagnosis is essential to ensure effective treatment. Here, we present the case of a 62-year-old male who presented with symptoms of COVID-19 acute respiratory distress. There was diffuse subcutaneous emphysema in the face, neck, shoulder, and chest wall on clinical examination. The patient was started on oxygenation via a non-rebreather mask. On further evaluation, his chest X-ray revealed bilateral peripheral opacities in the lung fields, bilateral pneumothorax, and subcutaneous emphysema, after which intercostal drainage tubes were inserted. The patient's oxygen saturation was not satisfactory, and he was switched to a high-flow nasal cannula. However, his condition deteriorated, and he was put on mechanical ventilation and inotropic support. Despite our best efforts, the patient succumbed to the disease. We want to emphasize the importance of this adverse event despite his nonsmoking history and the exclusion of positive pressure ventilation. Although benign, early diagnosis of this condition is vital, as the condition could lead to worse morbidity if left unrecognized.

Background: An extremely rare manifestation of perigraft seroma (PGS), in which a dense, semisolid jelly-like mass had formed around the shunt instead of the standard fluid-like form of the usual seroma, leading to misdiagnosis with other entities, such as tumors around the synthetic arterio-venous shunt (AVS) was presented.

Case Report: A 64-year-old male with multiple myeloma post autologous bone marrow transplant with a renal impairment, presented with a rare form of PGS, which was noticed 2 months after placing a synthetic AVS vascular graft. The mass increased in size, and multiple attempts for excision failed due to recurrence, which led to tumor misdiagnosis. The mass reoccurrence stopped completely only after the radical shunt removal.

Conclusion: This case report revealed a rare form of PGS, in which the seroma was represented as a firm, semisolid jelly-like mass rather than the typical fluid type transudate seroma. Despite its rarity, it was associated with a high recurrence rate because unlike the standard perishunt seroma, this semisolid jelly-like material could neither be aspirated, nor could it be resected en-bloc, leading to shunting dysfunction. Its management included advanced imaging and a high probability of shunt removal or replacement.

Varicella-zoster (VZ) meningitis is uncommon in patients with immunocompetence and usually presents with typical rash and fever. However, VZ meningitis can rarely present with symptoms of intracranial hypertension without the classic manifestations. Herein, we describe a 17-year-old female teen who presented with intractable headache and vomiting and diagnosed with VZ meningitis. Her symptoms remarkably improved after a lumbar puncture and acyclovir therapy.

Background: Rituximab is used as second-line therapy in patients with immune thrombocytopenic purpura (ITP) who do not respond to first-line management. The response rate for Rituximab is variable in different populations ranging from 30% to 90%. The adverse effects of rituximab in patients with ITP range from infusion site reactions to the reactivation of hepatitis B virus and progressive multifocal leukoencephalopathy and interpopulation variation.

Methods: We conducted a single-center, retrospective study in Qatar's National Center for Cancer Care & Research. The study included patients with chronic refractory ITP who received rituximab as second-line therapy. Descriptive and summary statistics were used to describe the sociodemographic parameters of the study cohort.

Results: Of the 41 patients with chronic ITP, 26 were Arabs, 12 were Asians, and 3 were of other ethnicities. Rituximab was associated with an overall response rate of 80.4%. Arabic patients had the highest clinical response (84.6%) among the ethnicities with the lowest adverse effects (11.5%). Asians had a response rate of 66.6%, and adverse effects were seen in 16.7% of the patients.

Conclusions: In chronic refractory ITP, rituximab appears to have a better clinical response in the Arabic population with minimal toxicity than in other ethnicities.

Background: In March 2020, Qatar started reporting increased numbers of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causing coronavirus disease 2019 (COVID-19). National preventive measures were implemented, and a testing plan was developed to respond to the pandemic with the Primary Health Care Corporation (PHCC) as the central element. PHCC is the main public primary healthcare provider in Qatar and it operates in 27 health centers with around 1.4 million registered individuals as of January 1, 2020. The latter population was distributed across four main nationality groups; Middle Eastern and North African (51.5%), Asian (41.2%), African (2.4%), and others (5.1%). At the primary healthcare level in Qatar, this study describes the epidemiological characteristics of individuals registered at PHCC who had contracted COVID-19 in 2020 during the first wave before the vaccination phase and examines the factors associated with the positivity rate.

Methods: Retrospective data analysis was conducted for persons screened for SARS-CoV-2 in primary healthcare health centers in Qatar between March 11 and December 31, 2020. The study analyzed the demographic characteristics of the tested persons and noncommunicable disease burden, positivity rate by month, nationality, and age-group, and the factors associated with the positivity rate.

Results: Between March 11 and December 31, 2020, PHCC tested 379,247 persons for SARS-CoV-2, with a median age (IQR) of 32 (21–42) years. Of these, 57.0% were from the Middle East and North Africa, and 32.5% were originally from Asia. Overall, 10.9% had diabetes mellitus and 11.3% had hypertension. The epidemiological curve showed a steep increase in the positivity rate from March till May 2020, at the highest rate of 37.5% in May 2020. The highest positivity rate was observed among Asian males at 15.7%. The positivity rate was the lowest among the age-group aged 60 years and above. It was almost the same among the tested persons for SARS-CoV-2 in the three main age groups (0–18, 19–39, 40–59) at 10.1%, 12.3%, and 12.2%, respectively. In a multi regression model, being a male was associated with a higher risk (OR 1.15; 95% CI 1.13–1.17). Asians were at higher risk than those originally from the Middle East and North Africa (OR 1.29; 95% CI 1.27–1.32). COVID-19 infection was higher among those presenting clinical symptoms than asymptomatic individuals (OR. 4.52; 95% CI 4.42–4.64).

Conclusion: The epidemic among the PHCC-registered population predominantly affected younger ages and males, namely, coming from Asia. At the primary healthcare level, the COVID-19 infection rate was higher among those who presented with clinical symptoms. The lowest positivity rate among individuals >60 years may reflect the effectiveness of public health measures related to the high-risk group. Scaled-up testing at the primary healthcare level helped to detect more cases during the peak of the first wave and was reflected in a steady increase in the positivity rate flattened later due to the established public health measures.

Background: It remains unclear whether patients with autoimmune rheumatic diseases (ARDs) are at a higher risk of poor outcomes from a SARS-CoV-2 infection. We evaluated whether patients with an ARDs infected with SARS-CoV-2 were at a higher risk of a poorer outcome than those without an ARDs.

Methods: Patients with an ARDs infected with SARS-CoV-2 were matched to control patients without a known ARDs. Matching was performed according to age ( ± 6 years) and sex at a case-to-control ratio of 1:3. Demographic and clinical data were extracted from the databases and were compared between the two groups. Severe SARS-CoV-2 infection was the primary outcome and was defined as the requirement for oxygen therapy support, the need for invasive or noninvasive mechanical ventilation, or the use of glucocorticoids.

Results: A total of 141 patients with an ARDs were matched to 398 patients who formed the control group. The mean ages (SD) of the ARDs and non-ARDs groups were 44.4 years (11.4) and 43.4 years (12.2). Women accounted for 58.8% of the ARDs group and 56.3% of the control group (p = 0.59). Demographics and comorbidities were balanced between the groups. ARDs included connective tissue disease in 43 (30.3%) patients, inflammatory arthritis in 92 (65.2%), and other ARDs in 8 (5.7%). ARDs medications included biological/targeted synthetic disease-modifying antirheumatic drugs (b/ts-DMARDs) in 28 (15.6%) patients, conventional synthetic DMARDs in 95 (67.4%), and immunosuppressive antimetabolites in 13 (9.2%). The ARDs group had more respiratory and gastrointestinal symptoms related to SARS-CoV-2 infection than the control group (24.8% and 20.6% vs. 10% and 5.3%, respectively; p <  0.001 for both). Severe SARS-CoV-2 infection was more common in the ARDs group than in the control group (14.9% vs. 5.8%; p <  0.001).

Conclusions: In this single-center matched cohort study, patients with an ARDs experienced more respiratory and gastrointestinal symptoms related to SARS-CoV-2 infection and had more severe infection than those from the control group. Therefore, patients with an ARDs require close observation during the coronavirus disease 2019 pandemic.

Background: Treatment options for patients with critical Coronavirus Disease 2019 (COVID-19) are limited. This study aimed to describe the clinical characteristics and outcomes associated with remdesivir therapy in patients with COVID-19 who require non-invasive (NIV) ventilation or invasive mechanical ventilation (IMV).

Methods: Data were retrospectively extracted for adults with COVID-19 confirmed using polymerase chain reaction (PCR) between August 1, 2020 and January 28, 2021 who received ≥ 48 hours of remdesivir therapy while on NIV or IMV. Clinical improvement was defined as two-category improvement on an eight-point ordinal severity scale.

Results: A total of 133 individuals were included, of which 114 (85.7%) were on NIV and 19 (14.3%) were on IMV at the time of remdesivir initiation. The majority of the patients were males (62.4%), and the median age was 56 years. All the patients received concomitant dexamethasone therapy. Remdesivir treatment was commenced after a median of 7 days from onset of symptoms and was continued for a median of 5 days.

Clinical improvement within 28 days was achieved in 101 patients (75.9%); among which, 78.1% and 63.2% were subjected to baseline NIV and IMV, respectively. Among the 11 (8.3%) patients who died of any cause by day 28, 9 (7.9%) and 2 (10.5%) were subjected to baseline NIV and IMV, respectively. The most frequent adverse events were sinus bradycardia (21, 13.1%) and alanine transaminase increase (18, 11.3%). Almost all adverse events were classified as Grades 1–3.

Conclusion: The use of remdesivir in combination with systemic corticosteroids is associated with high recovery rates and low all-cause mortality in patients with COVID-19 pneumonia who require NIV or IMV. The results need confirmation from clinical trials of appropriate design and size.

Background: Intellectual disability (ID) is a common condition that consists of a heterogeneous group of clinical conditions with different etiologies, including genetic conditions. Identifying those with a genetic cause results in better clinical management.

Aim: To identify the genetic etiology of ID in adult patients with unknown etiology presenting to a specialist learning disability service in Qatar.

Methods: Retrospective review of chart notes of patients referred for ID service from January 1, 2015 to January 1, 2020.

Results: Of the 228 patients, 82 had a known cause of ID and did not require genetic testing, 22 had an unknown cause and underwent genetic testing, and 124 had an unknown cause and did not undergo genetic testing. Of the 82 patients with a known cause of ID, about one-half had an autistic spectrum disorder (ASD) and 18 patients had a genetic disorder. Of the 22 patients who underwent genetic testing, 2 were positive for the Fragile-X mental retardation 1 gene, 3 underwent chromosomal microarray, and 7 underwent whole-exome sequencing. Seven abnormal genes were identified.

Conclusions: Identifying the underlying genetic etiology of patients with ID has major implications for diagnostic and therapeutic approaches. Additionally, it guides a prediction of the natural history of the disease and makes it possible to test at-risk family members.

Introduction: Ceftriaxone, a third-generation cephalosporin, is frequently used for the treatment of various bacterial infections as a broad-spectrum antibiotic for many decades. Although ceftriaxone is a well-tolerated drug in most cases, it can lead to serious liver injury, which can be a real challenge to the treating physician. Given the potentially serious adverse effects that can vary from mild biochemical abnormalities to complete liver failure, we intend to assess the spectrum of liver injury based on biochemical criteria for patients treated with ceftriaxone for common bacterial infections in Qatar.Objectives: This study aimed to explore the incidence of ceftriaxone-induced liver injury at Hazm Mebaireek General Hospital, Qatar, and to evaluate the relationship of the ceftriaxone dose, if any, with liver dysfunction.Methods: This retrospective study included hospitalized adult patients treated with ceftriaxone at our hospital from January 2019 to December 2019 and analyzed demographic and clinical data obtained from electronic medical records. This study determined the incidence of liver injury (primary outcome) in patients treated with ceftriaxone (2 g/day) for ≥ 2 consecutive days by reviewing liver function test results until the day of discharge and at the first outpatient follow-up.

Results: The final data analysis included a total of 634 patients admitted and treated with ceftriaxone from January 2019 to December 2019.In the multivariate analysis with propensity score adjustment, ceftriaxone was independently associated with liver injury, especially when combined with other agents utilizing hepatic metabolism.Conclusions: Ceftriaxone was associated with a significantly higher incidence of liver injury (19.7%) when used along with other medications that are metabolized in the liver, as found in the present study compared with other similar studies (approximately 2.9%–13.9%). Furthermore, the incidence was too high to be ignored in clinical practice.

Introduction: Coronavirus disease 2019 (COVID-19) can present with various neuropsychiatric manifestations. This study reports on patients with COVID-19 who were referred to the consultation–liaison (CL) psychiatry services in Qatar and compares the clinical and sociodemographic characteristics of those diagnosed with delirium versus other psychiatric diagnoses. Methods: This is a retrospective review of the first 100 consecutive patients with COVID-19 who were referred to the CL services. Results: Within the total cohort (n=100), most patients (92%) were male, and the mean age was 46 years. About 27% of patients had asymptomatic COVID-19, 35% had a past psychiatric history, and 48% reported pandemic related psychosocial stress. Delirium was the most common psychiatric diagnosis (n=29), followed by acute stress reaction/adjustment disorder, depression, mania, anxiety, non-affective psychosis, and dementia. Among patients with delirium, agitation was the most common symptom (76%), 86% were treated with psychotropic medications, and 17% died. Higher age, longer hospital stays, lower oxygen saturation, lower lymphocytic count, and higher C-reactive protein (CRP) values were significantly associated with delirium versus other psychiatric diagnoses. Higher age and lower oxygen saturations predicted delirium.Conclusion: Delirium was associated with a range of clinical variables and had significant mortality, despite the relatively young age of the patients. COVID-19 should be considered in patients presenting with delirium. Finally, early identification and management of delirium should be integral to COVID-19 protocols.

Neuromyelitis optica spectrum disorder (NMOSD) is an autoimmune astrocytopathy against foot processes of aquaporin-4 (AQP4) water channels. Patients with NMOSD tend to have other coexisting autoimmune/connective tissue diseases. However, AQP-4-antibody-positive NMOSD coexisting with ankylosing spondylitis (AS) is rare. AS is an immune-mediated disorder, a subset of axial spondyloarthropathies, which commonly manifests as chronic inflammatory back pain in young people, and it has a strong association with HLA-B27. In this study, a 35-year-old Indian man with an undiagnosed progressive axial spondyloarthropathy (i.e., AS) is reported presenting with acute-onset longitudinally extensive transverse myelitis, a clinical subset of NMOSD.

Neuromyelitis optica spectrum disorder (NMOSD), a primary demyelinating disorder of the central nervous system (CNS), is an autoimmune astrocytopathy against foot processes of aquaporin-4 (AQP4) water channels, which manifests with optic neuritis, longitudinally extensive transverse myelitis (LETM), area-postrema syndrome, brainstem syndrome diencephalic syndrome, and cerebral syndrome.^1–4

Ankylosing spondylitis (AS) is an immune-mediated disorder, a subset of axial spondyloarthropathies, which commonly manifests as chronic inflammatory back pain in young people, and it has a strong association with HLA-B27.^5,6 AS characteristically targets the axial skeleton, peripheral joints, entheses (connective tissues between tendons/ligaments and bones), and gut.^5,6

Patients with NMOSD tend to have other coexisting autoimmune/connective tissue diseases.⁷ For example, cases with NMOSD and multiple sclerosis, which are other autoimmune primary demyelinating disorders of the CNS, have been reported.^8,9 However, concurrent existence of AS and NMOSD in the same patient even over years of disease course is rare.^10,11 In addition, studies describing neurological manifestations of AS are limited,¹² and they focus on joint inflammation and long-standing bony pathology (ankylosis) related to compressive myelopathy, myelo-radiculopathy, and cauda equina syndromes.^12,13

The authors present a case of a young Indian man with an undiagnosed progressive AS (misdiagnosed and mismanaged by an indigenous medical practitioner) presenting with acute-onset LETM variant of AQP4-positive NMOSD.

A 35-year-old healthy, non-comorbid man from rural India came to the outpatient department with complaints of persistent tingling, numbness, and weakness of both lower limbs (right more than left) for 10 days. The clinical picture showed acute-onset urinary retention, which was relieved by urinary catheterization. An indigenous medical practitioner had prescribed drugs to treat a urinary tract infection. His weakness gradually progressed over the following week, causing him to become bedridden. During the removal of the catheter, he felt urgency, increased frequency of micturition, and overt urinary incontinence. He gave no history suggestive of any girdle-like sensations, root/radicular/tract pain, vertebral pain, trauma, recent vaccination, and diarrheal or febrile illness.

For the last 8 months, he had a complaint of an insidious-onset, persistent, bilateral, dull aching pain in the gluteal region accompanied by low-back pain and morning stiffness up to 1 h, which markedly improved with activity and reoccurred following long periods of inactivity. He sometimes had to rise in the middle of the night because of excruciating pain, which could be relieved after moving around the room and corridors for half an hour. He was taking over-the-counter diclofenac tablets for pain relief prescribed by some indigenous medical practitioners who told him that it was due to overwork in agricultural fields, that is, mechanical back pain. He also had a normal X-ray of the lumbosacral spine.

He had no addiction liabilities, and none of the family members had ever suffered from a similar kind of illness. He had never consulted any trained medical practitioner, as his previous back-pain-related symptoms responded well to the tablets prescribed by the indigenous medical practitioner(s).

During examination, he was found to have recent-onset, asymmetric spastic paraparesis (right more than left) with upper motor neuron-type urinary bladder symptoms. Cognitive assessment (assessed by the Montreal cognitive assessment test) was normal, and posterior column sensations were preserved. Sensory system examination revealed no definite sensory level. Except for the paretic lower limbs, cerebellar functions were normal in other regions. Neuro-ophthalmological examinations were also normal, and no signs of meningeal irritation were observed.

The history and course of the disease and clinical examinations were analyzed. Selective tractopathy (early and predominant motor and autonomic tract affection) was suggested for an intramedullary demyelinating pathology affecting the anterior central cord. This case was initially classified as acute-onset non-compressive myelopathy at the lower cervical/upper dorsal region level in a patient with a pre-existing axial spondyloarthropathy.

Complete blood cell count; liver, kidney, and thyroid function tests; and plasma glucose and electrolytes were normal, except for an increased erythrocyte sedimentation rate (66 mm in the first hour). Magnetic resonance imaging (MRI) of the spinal cord revealed a demyelinating LETM from C5 to D4 level (Figure 1). Meanwhile, an MRI of the sacroiliac joints revealed bilateral sacroiliitis. Brain and orbital MRIs were devoid of any lesions. Anti-aquaporin 4 (AQP-4) antibodies were tested by cell-based assay in serum and cerebrospinal fluid (CSF), and both were positive. CSF further revealed lymphocytic pleocytosis and increased intrathecal protein production. Visually evoked potential recordings were also normal. In addition, anti-myelin oligodendrocyte glycoprotein antibodies were negative. Anti-nuclear antibody (ANA), ANA-profile, autoimmune vasculitis profile (c-ANCA, p-ANCA), neurovirus panel (i.e., polymerase chain reaction for adenovirus, Epstein–Barr virus, herpes simplex viruses 1 and 2, human herpesviruses 6 and 7, cytomegalovirus, enteroviruses, varicella-zoster virus, Japanese encephalitis, and dengue virus), CSF-polymerase chain reaction for Mycobacterium tuberculosis, angiotensin-converting enzyme, anti-phospholipid, and anti-thyroid antibodies were negative. Anti-CCP-antibody and rheumatoid factor were also negative, including creatine phosphokinase level and serum vitamin B12. Moreover, serologies for hepatitis B, C, human immunodeficiency virus, and scrub typhus were negative. However, HLA-B27 assay was positive. The final diagnosis was AQP4-positive NMOSD associated with AS. He was placed on pulse intravenous methylprednisolone (1 g/day for 5 days). Consequently, his lower limb power improved remarkably. Cyclical rituximab therapy was initiated to prevent relapses. At 3-month follow-up, he had no residual neurological deficit except for persistence of paresthesias. Neuroimaging and visually evoked potential studies revealed no active or new lesions. After 6 months of therapy, a subjective and objective improvement was observed in disease severity based on the Ankylosing Spondylitis Disease Activity Score.Figure 1.  Magnetic resonance imaging of the spinal cord revealed a lesion showing a hyperintense signal on sagittal T2-weighted imaging (A), sagittal short tau inversion recovery sequence (B), and axial T2-weighted imaging (C), indicating a longitudinally extensive demyelinating lesion from the C5 to the D4 level.

Our patient satisfied the new Assessment of SpondyloArthritis International Society diagnostic/classification criteria for AS and the Wingerchuk criteria for NMOSD,^4,14 an association that has been rarely reported.^10,11

Amid the extra-articular complications of long-standing AS, neurological manifestations are considered infrequent.¹⁵ However, subclinical neurological complications may be frequent in AS.¹² Common neurological manifestations result from bony (vertebral) ankylosis, subluxation of joints, ossification of anterior and posterior longitudinal ligaments, secondary spinal canal stenosis, bony (vertebral) fractures, and subsequent compressions over nerve radicles/roots/cauda equina, and inflammation-related (entrapment) peripheral neuropathies.^12,16,17 Acute transverse myelitis can occur as a subset of several primary demyelinating disorders of the CNS (i.e., multiple sclerosis, NMOSD, myelin oligodendrocyte glycoprotein antibody disease, and acute disseminated encephalomyelitis) and various systemic autoimmune connective tissue disorders (i.e., systemic lupus erythematosus, mixed connective tissue disease, Sjögren syndrome, inflammatory bowel disease, and neurosarcoidosis).¹⁸ Acute transverse myelitis (short or long segment) is an infrequent extra-articular complication of AS.¹⁸ It has been reported to evolve either as a distinct neurological complication of AS, or it may develop secondary to TNF-alpha-inhibitor therapy for the treatment of AS.^18,19

AS is a heritable inflammatory spondyloarthropathy that primarily affects the axial skeleton, which is mediated by T-cells; B-cells only play a minor role.⁵ On the contrary, the key for the pathogenesis of NMOSD is the production of autoantibodies against AQP-4 channels expressed on astrocytes, leading to complement-mediated damage, with ensuing demyelination. Myelitis usually shows high signal intensity on the T2‐weighted image and contrast enhancement in the spinal cord.^1–4

Despite the difference in molecular mechanisms, the diagnosis of these diseases in the same individual may not be coincidental. Recent evidence has shown T-cell-mediated inflammatory responses in cases of NMOSD.²⁰ In particular, Th17 and Th2-related cytokines are elevated in the CSF of NMO patients.²⁰ Environmental factors such as Escherichia coli have also been proven to aggravate autoimmunity in AS and NMOSD (however, body fluid cultures for Escherichia coli, performed in our patient, showed similar association, and they were found negative two times).^21,22 Although large-scale epidemiological studies investigating the underlying pathogenesis related to these diseases are lacking, studies have demonstrated an increased incidence of optic neuritis among patients with AS.²³

Systemic sclerosis and mixed and undifferentiated connective tissue diseases were excluded after expert opinions (from two board-certified rheumatologists and two dermatologists) because of the lack of suggestive clinical findings (e.g., absence of skin thickening, salt-and-pepper appearance, nail changes, Mauskopf facies, sclerodactyly, calcinosis cutis, Raynaud’s phenomenon, other cutaneous manifestations, pulmonary arterial hypertension/interstitial lung disease, dysphagia, muscular pain/weakness renal impairments, absence of ANA, anti-centromere antibodies, anti-Scl-70, PM-Scl antibodies, anti-ds DNA, PCNA, CENP-B, anti-nucleosomes, anti-Smith, anti-U1-RNP, anti-Jo1, anti-Mi2, anti-Ro52, anti-La antibodies, and normal C3 and C4 complement levels) (The European League Against Rheumatism and the American College of Rheumatology classification criteria 2019).²⁴

Finally, our patient was treated with intravenous steroids followed by rituximab infusions, a monoclonal anti-CD20 antibody directed against B-cells. In particular, this patient clinically and radiologically responded to immunomodulatory drugs, which might support a possible common pathogenic basis of the two processes. TNF-alpha inhibitors are commonly used as novel therapeutics in AS; however, they can potentially result in serious complications, that is, secondary demyelinating disorders.²⁵ However, such inhibitors in this patient were not used. When used in cases of AS, they show satisfactory results.^25,26 Therefore, it was decided to treat him with rituximab only without adding any second immunomodulatory. Other possible therapeutic options include cyclophosphamide and mycophenolate mofetil, but they were not used because of their low efficacy–safety balance. Moreover, plasmapheresis was not available in our specific setting, despite solid evidence that early treatment with therapeutic strategy (5–7 courses) provides good long-term outcomes in patients with NMOSD.²⁷

Therefore, when dealing with a case of acute non-compressive myelopathy, history and clinical examination are important to determine the potential underlying etiology and identify an undermined systemic disorder with apparently unrelated non-specific features. Connective tissue disorders should always be considered as a differential diagnosis and be ruled out in all cases of either seropositive or seronegative NMOSD. A diagnosis of AS should be considered in relevant circumstances when dealing with a case of isolated seronegative LETM. Moreover, early diagnosis and treatment of AS are quintessential to prevent lifelong distressing disabilities. However, whether patients with AS have any extra predilection to develop NMOSD throughout their life requires further studies.

Background: Pregnancy affects a woman's susceptibility to and severity of certain infectious diseases. Central neuraxial block for analgesia during labor is superior to nonneuraxial methods in efficacy, safety, and maternal satisfaction. Although Coronavirus disease (COVID-19) can be vertically transmitted from mother to fetus, little is known about the effects of COVID-19 on pregnant women or about anesthesia management and the risk of adverse effects related to neuraxial techniques in women with untreated COVID-19 during gestation.

Aim: This investigation assesses the effects of neuraxial analgesia during labor of COVID-19-positive parturients on their hemodynamic stability.

Results: The study was conducted on 64 patients and involved 32 parturients positive for SARS-CoV-2 by polymerase chain reaction (PCR) and a similar number of control “negative” patients. The affected group had an uneventful course during gestation. Seven were positive for ground-glass opacities on chest X-rays, and none underwent computed tomography (CT) scans. Two neonates were PCR-positive for SARS-CoV-2, and all 32 neonates were released from the hospital. No clinical differences were observed between the neonates in the COVID-19 and control groups. Although parturients in both groups were hemodynamically stable, hemodynamic stability was subnormal in the COVID-19 group regarding blood pressure, oxygen saturation, heart rate, and body temperature. None of the women in either group required a vasopressor or oxygen supplementation during delivery. No other clinical differences were observed between the COVID-19 and control groups.

Conclusion: This is the first case-controlled study testing the anesthetic implications of neuraxial labor analgesia in pregnant, COVID-19-positive women. Although management of neuraxial labor analgesia did not differ in pregnant women positive and negative for COVID-19, their hemodynamic characteristics differed significantly. Therefore, care is required to prevent adverse outcomes in pregnant women positive for COVID-19.

Background: Elite professional sports events involving mass gatherings carry a high risk of viral transmission during the coronavirus disease of 2019 (COVID-19) pandemic. We describe the potential impact of resuming professional football leagues involving international participants adhering to a strict Bio-secure bubble protocol and investigate the consequences of spectators/fan attendance at such mass events during the ongoing COVID-19 pandemic in Qatar.

Methods: We conducted a descriptive cohort study involving football players, referees, match officials, local organizing committee (LOC) members, hotel and security staff working in close coordination, and over 10,000 spectators from the Asian Football Confederation (AFC) Champions League (East) and the final match. The study covered almost four weeks of the event (November 19 to December 19, 2020) under a robust Bio-secure bubble protocol. It included extensive severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) RT-PCR (reverse transcription-polymerase chain reaction) every 3–6 days and clinical symptom monitoring on and off the field. Target variables included positive RT-PCR results and clinical symptom monitoring among participants, and rapid antigen testing for fan attendance to examine their safe return to the stadiums.

Results: A total of 12,250 RT-PCR tests involving 3158 individuals in the Bio-secure bubble were done over one month for all the AFC (East) matches, including the final match. Overall, 44 matches involving 16 teams were played. During the championship, only five individuals (three LOC members and two match officials) returned positive for COVID-19 infections. Four individuals (three team staff/officials and one person outside the Bio-secure bubble) had reactive results. None of the players tested positive for COVID-19 infection. All individuals testing positive were asymptomatic or had mild symptoms, with no one requiring hospitalization other than symptomatic treatment. The overall positivity rate was 0.15% for the entire duration of the AFC (East) Champions League. For the final match, a total of 10,320 rapid antigen tests were done for spectators, of which only one test was positive for COVID-19.

Conclusions: This report shows a very low incidence rate of COVID-19 infections during mass gathering events at the international level. For the resumption of football with spectators, careful mitigation strategies should be considered to reduce the risk of transmission to a sufficiently safe level. This may require proper coordination and measures (i.e., physical distancing, testing, entry, and exit routes in the stadium, and seating arrangement inside the stadium with limited attendance). Based on this, during the ongoing COVID-19 pandemic, the supervised and controlled resumption of football matches with spectators can be done safely provided that a strict Bio-securebubble protocol has been implemented.

Background: Dyslipidaemia is frequently associated with type 2 diabetes mellitus and it is the major contributor to cardiovascular diseases among type 2 diabetic patients. Despite the fact that several researches have proven the association between glycemic control and dylipidemia in type 2 diabetic patients, the results are rather varied.

Objectives: The aim of the study is to investigate the clinical relevance of lipid profile as predictive biochemical model for glycemic control in type 2 diabetic patients.

Methods: A cross-sectional study including 329 type 2 diabetic patients was done in Al-Sadr Teaching Hospital, Basrah, Iraq. Brief history, clinical examination, and investigations including fasting plasma glucose, lipid profile, and glycosylated hemoglobin were done. HbA1c >7% was considered as poor glycemic control. Receiver operator characteristics (ROC) analysis and logistic regression analysis were used to evaluate the association between lipid profile and HbA1c level.

Results: Out of 329 diabetic patients, 278 (84.5%) showed poor glycemic control. The univariate analysis showed a significant association between lipid parameters and poor glycemic control. ROC and logistic regression analyses found that TC/HDL (OR: 4.94; 95% CI: 2.35–10.41; P < 0.001) and LDL/HDL (OR: 4.63; 95% CI: 1.96–10.98; P < 0.001) were the only significant independent predictors of glycemic control, while non-HDL cholesterol was a weak predictor of glycemic control despite its significant association (P = 0.02).

Conclusion: LDL/HDL and TC/HDL ratios reveal promising indicators for predicting glycemic control in type 2 diabetic patients.

Thrombolysis is an established therapeutic modality for patients with high-risk (and some selected intermediate-risk) pulmonary embolism (PE) with hemodynamic instability. Physicians sometimes experience cases where both a high-risk PE and thrombocytopenia coexist. Although thrombocytopenia of <  100 × 10³/mm³ is considered a contraindication in patients with ischemic stroke, the safety and outcomes of thrombolysis in patients with acute PE and thrombocytopenia are unknown. This systemic review aimed to pool data on the safety and outcomes of thrombolysis use in patients with PE and platelet count less than 150 × 10³/mm³. Patients’ demographics, clinical characteristics, management, type of thrombolytic therapy, and outcomes were extracted and analyzed. Of 283 articles identified through the systematic search, 11 case reports fulfilled the inclusion criteria. The mean age of the patients was 52.27 years, and 54.5% were women. The median platelet level before thrombolysis was 65.50 × 10³/mm³. Before thrombolysis was initiated, the lowest and highest platelet levels were 29 × 10³/mm³ and 105 × 10³/mm³, respectively. Alteplase was used in 10 patients and urokinase in one patient. One patient who had a massive PE died of aspiration pneumonia. Interestingly, no thrombocytopenia-related complications were reported. This systematic review highlights the potential benefits and safety of thrombolysis in patients with acute PE in the context of thrombocytopenia. Nevertheless, data available in the literature concerning this topic are scarce and limited to case reports. More extensive studies on the use of thrombolysis in patients with PE and thrombocytopenia are desperately needed.

Systematic review registration: The protocol has been registered in the International Prospective Register of Systematic Reviews (PROSPERO): CRD42021286415.

Background: The World Health Organization declared the coronavirus disease-2019 (COVID-19) a pandemic in December 2019. COVID-19 can affect most organs of the body but predominantly affects the lungs. Chest infection is associated with hyponatremia primarily due to inappropriate ectopic secretion of antidiuretic hormone. We conducted a six-month retrospective observational study to evaluate the relationship between chest X-ray (CXR) radiological findings and serum sodium levels. Our secondary goal was to assess the relationship between CXR findings and patient outcomes.

Aim of the Study: To assess the relationship between the initial CXR findings, hyponatremia severity, and outcome in COVID-19 infected patients.

Materials and methods: We conducted a retrospective review of CXR findings of COVID-19 patients aged > 18 years. The patients were healthy and had no history of hyponatremia before COVID-19 infection. All recruited patients were admitted to one of four hospitals in Qatar (Hazm Mebaireek General Hospital, Communicable Disease Center, and all affiliated quarantine centers managed under the Communicable Disease Centre, Mesaieed Hospital, and Ras Laffan Hospital) between March and June 2020. We excluded patients with factors that contributed to hyponatremia. Three score grades were established to describe the CXR findings. Patients were divided into three groups by the principal researcher according to their serum sodium levels. A radiologist evaluated the CXR findings with the patient and group information obscured. The principal researcher collected the X-ray scores for analysis with the serum sodium levels. We used SPSS for Windows, Version 15.0. (SPSS Inc., Chicago, IL, USA) and STATA Package Version 12.0 (StataCorp, College Station, TX, USA) to analyze the data. A p-value ≤  0.05 was considered significant.

Results: A total of 414 CXR patients with COVID-19 were recruited; 275 patients had hyponatremia and 139 had normal sodium levels and were used as the control group. Patients with normal serum sodium and hyponatremia were classified into three categories based on the CXR findings. Grade 0 (95), Grade 1 (43), and Grade 2 (137) hyponatremic patients were reported. The mean sodium levels were 133.6, 131.3, and 127.2 mmol/L for Grades 0, 1, and 2, respectively (p < 0.001). More than 95% of the patients who developed hyponatremia were >30 years. Moderate and severe hyponatremia was more prevalent in patients with Grade 1 or Grade 2 CXR findings and were >30 years.

Conclusion: Serum sodium levels in COVID-19 patients correlated well with the severity of the CXR findings observed at the early disease stage. Furthermore, simple CXR scores can be used to identify COVID-19 patients at a higher risk of hyponatremia, length of hospital stay, medical care support type, and mortality.

Introduction: Vitamin D deficiency is a worldwide public health concern, which can lead to severe diseases, such as rickets in children and osteomalacia in adults. Most studies have compared equimolar unit-to-unit doses of vitamin D2 and D3.

Objectives: The current study aimed to answer the research question: “How effective is vitamin D2 (600,000 U/1.5 ml) compared to vitamin D3 (300,000 U/1 ml) parenteral supplementation for raising serum vitamin D levels in adult patients treated in a primary health care setting?”

Setting: Primary Health Care Corporation (PHCC) runs 28 health centers distributed throughout the State of Qatar and its capital city, Doha. Qatar is on the east coast of the Arabic peninsula, with very hot and sunny summers and a desert climate.

Study design: This was a retrospective observational cohort study.

Method: A total of 15,716 participants were recruited following ethical approval. They were identified by electronic medical records (EMR) describing the clinical encounters of individuals aged 18 to 60-years-old who attended a health center operated by the PHCC during the 3.5-year study period from January 1, 2017 to June 30, 2020. The PHCC EMR system uses SNOMED codes (a systematically organized computer-processable collection of medical terms providing codes, names, synonyms, and definitions implemented for clinical documentation and reporting). Four study groups were created depending on the type of vitamin D injection and the oral form of replacement therapy. The analysis scheme used the serum vitamin D level within the preceding 4 weeks (pretreatment), followed by administration of the treatment dose. The post-treatment serum testing value should have been available within a maximum of 12 weeks. The Statistical Package for Social Sciences (IBMSPSS; IBM Corp., Armonk, NY, USA) version 23 software was used for the statistical analysis.

Results: Four treatment options were compared, including a vitamin D2 injection, a vitamin D3 injection, combined use of a vitamin D2 injection + a D2 tablet, and combined use of a vitamin D3 injection + a D2 tablet. All four treatment groups were associated with a statistically significant increase in serum vitamin D within a maximum of 12 weeks of follow-up. The vitamin D2 injection alone was associated with the lowest increase in serum concentration by a mean of 3.2 ng/ml. In contrast, the vitamin D3 injection alone or with a D2 tablet increased serum vitamin D by 6.1 and 5.6 ng/ml, respectively. Using the combination of a vitamin D2 injection and a tablet only added a marginal increase of 2.3 ng/ml in serum vitamin D on top of the 3.2 ng/ml increase attained after administering the D2 injection alone.

Conclusion: Utilizing vitamin D3 in an injectable form is the best choice to restore severe vitamin D deficiency. Furthermore, it was superior to the injectable form of vitamin D2, even though vitamin D2 has double the molar units.

Introduction: Healthcare research contributes to the well-being of a population; hence, it is important to use the right system to ensure that junior researchers develop the required skills. Current research-strengthening and capacity development programs might lack a research process-based common framework or model leading to variable and suboptimal outcomes. This study aimed to describe the development and evaluation of a model for health research-capacity development at both individual and institutional levels in a Joint Commission International-accredited governmental healthcare organization in Qatar.

Methods: This retrospective observational study evaluated a research support system employed in Qatar for 1 year and constituted of16 stations, each covering a different topic and supported by an experienced faculty member. We recorded how many faculty members were involved and how many people accessed which stations. We developed an outcomes logistic model and obtained feedback about their experience of using the research support system through a short survey.

Results: Twenty-one faculty members supported a total of 77 participants, representing various professions and specialties. The majority of the participants received support on multiple stations, and the most solicited were study design and methodology (n = 45, 58.4%) and research idea (n = 29, 37.7%). The most common type of research that participants required support for was clinical research (n = 65, 84.4%). Moreover, 58.4% of the participants answered the survey, and their responses attested to their perceived benefit of making use of the research support system.

Conclusion: The research support system presented was positively evaluated by participants and promoted networking. Such aspects are favorable to the development of a research culture within an organization and would be a good addition for implementation in universities running healthcare programs and hospitals with residency programs and a large and varied healthcare workforce. This would contribute to the development of health-related research capacity and quality of research outputs in these institutions.

Background: Autoimmune rheumatic diseases (ARDs) are characterized by immune dysfunction and associated with an increased risk of infections, which were of significant concern during the coronavirus disease 2019 (COVID-19) pandemic. Variable rates of COVID-19 incidence have been reported in patients with ARDs; however, the true effect of this infection on this patient population is still unclear. We, therefore, aimed to evaluate the COVID-19 prevalence among a multiethnic cohort of patients with ARDs in Qatar.

Material and Methods: We used telephonic surveys to collect demographic and clinical information of patients with ARD in Qatar between April 1 and July 31, 2020, including any close contact with a COVID-19 case at home or work and polymerase chain reaction (PCR)-confirmed COVID-19 diagnosis. An electronic medical records review was conducted to verify pertinent data collected through the surveys. Prevalence with 95% confidence interval (CI), Student's t-tests, and chi-square/Fisher's exact tests were used for univariate analyses, whereas multivariate logistic regression was used to identify factors associated with COVID-19.

Results: The study included 700 patients with ARD (mean age, 43.2 ± 12.3 years), and 73% were female. Until July 2020, 75 (11%, 95% CI 9%–13%) patients had COVID-19. Factors associated with COVID-19 included being a man (adjusted odds ratio [aOR] 2.56, 95% CI 1.35–4.88, p = 0.01) and having close contact with a COVID-19 case (aOR 27.89, 95% CI 14.85–52.38, p = 0.01). Disease severity and rheumatic medications had no significant association with the odds of contracting COVID-19. In the 86 patients with ARD having close contact, the frequency of hydroxychloroquine utilization was lower in patients who contracted COVID-19 than in those who did not (35% vs 72.5%, p = 0.01).

Conclusions: In Qatar, patients with ARDs had an overall higher prevalence of COVID-19 than global estimates. Being male and having close contact with a COVID-19 case were strongly associated with COVID-19 as reported globally. The presence of comorbid conditions, disease-specific factors, and rheumatic medications had no significant effect on the risk of COVID-19 in our study suggesting alternative mechanisms to the increased prevalence.

The coronavirus disease (COVID-19) pandemic has had a significant worldwide impact since its emergence in 2019. End-stage kidney disease patients have been among the most vulnerable population affected and have a higher risk of acquiring infection and developing more severe disease. We have encountered three major COVID-19 waves in Qatar and they have required different strategies to overcome. The most recent wave was due to the Omicron variant characterized by higher transmissibility. The monthly incidence of COVID-19 infection during the Omicron wave in patients with end-stage renal disease peaked at 256 patients compared to 35 and 39 patients during the first and second waves, respectively. In addition, more than one-third of our dialysis staff became infected during this wave. Unlike the previous two waves, COVID-19 due to the Omicron variant was less severe with only 5% of hemodialysis patients requiring admission to the intensive care unit compared to 25% during the previous waves. The Omicron variant wave resulted in a crisis in our country due to the high number of non-hospitalized COVID-19 hemodialysis patients and the severe staff shortage. Several measures were taken to overcome the crisis, such as designating one facility to dialyze all COVID-19 ambulatory patients, reducing dialysis sessions to 3 hours, and introducing a fourth dialysis shift.

This article describes the challenges we faced in the ambulatory hemodialysis service during the Omicron wave and the measures taken in the COVID-19 and non-COVID-19 designated facilities to combat the crisis.

Background: COVID-19 infection has been spreading across the globe since the end of 2019, and it continues to cause chronic multi-system sequelae, of which thyroid dysfunction appears to be the major one. We have discussed here 10 cases of thyroid dysfunction after COVID-19 infection.

Methods: Case series report. From October 2020 to July 2021, a series of 10 cases of thyroid dysfunction after COVID-19 infection were recorded and managed in a single outpatient endocrine center in Doha, Qatar.

Cases presentation: We have reported 5 cases of Graves's hyperthyroidism, 2 of chronic primary hypothyroidism (including one with Grave's disease [GD]) who was treated through radioactive iodine (RAI) therapy, one case of subacute thyroiditis, one case with “Sick euthyroid disease,” and one case of central hypothyroidism. Presently, patients with GD are being treated with carbimazole and those with hypothyroidism are being treated with levothyroxine. The remaining patients had recovered with euthyroid.

Conclusion: This is the largest case series reported from a single center to date. The findings of this series indicate a bimodal distribution of thyroid dysfunction in patients with COVID-19 infection. A review of the literature and discussion of potential pathophysiological mechanisms has been presented. We have emphasized the importance of screening for thyroid dysfunction in “post-COVID-19” cases, considering that the prevalence may be underestimated.

Healthcare professionals monitoring vaccine-related adverse responses should be aware of COVID-19 vaccine-related acute respiratory distress syndrome to enable expeditious diagnosis and treatment. We report the first case of acute respiratory distress syndrome in a young pregnant woman, occurring immediately after a second dose of the Pfizer-BioNTech BNT16B2b2 mRNA COVID-19 vaccine and requiring a brief period of mechanical ventilation, with a good response to a two-week steroid course. She had recovered from mild COVID-19 infection requiring home isolation nine months prior to the current vaccination dose. Without depreciating the colossal benefit of the COVID-19 vaccine, vaccine-related acute respiratory distress syndrome should be listed as a possible adverse reaction.

Introduction: Severe acute respiratory syndrome-coronavirus 2 (SARSCoV2) pandemic has been an unceasing plight with a wide range of clinical presentations. The direct effects of the virus, increased use of medications, and lifestyle changes have contributed to the vulnerability to co-infections. Fungal and bacterial co-infections led to increased morbidity and mortality during the pandemic. Similarly, the surge of skin signs in conjunction with herpes zoster (HZ) manifestations has been reported. In this study, we pooled the data on the clinical characteristics of SARS-CoV-2 patients co-infected with HZ.

Methodology: Electronic databases including PubMed, Scopus, and Google Scholar were extensively searched to identify the relevant studies on HZ infection among the SARS-CoV-2 patients.

Results: A total of 79 patients (from case reports, series, and retrospective studies) were included in the analysis. Fever was the most common constitutional symptom recorded, followed by cough and dyspnea. A systemic rash was reported in 78.5% of cases with mild symptoms of HZ and SARS-CoV-2 in 87% and 76%, respectively. Only 19% of the cases presented during the prodrome period of SARS-CoV-2. HZV polymerase chain reaction (PCR) was positive in 8.9% of the cases, and the remaining were diagnosed clinically. SARS-CoV-2 PCR was reported positive in 65 cases (82.3%). Leukopenia was observed in 7 cases (8.9%) and lymphopenia in 25 (31.6%). All patients recovered through conservative treatment.

Conclusion: SARS-CoV-2 escalated the incidence of HZ reactivation. Most of the patients were seen with older individuals either simultaneously or a few days after the SARS-CoV-2 infection, but a few cases were reported during the asymptomatic prodrome period of SARS-CoV-2

Systemic lupus erythematosus is a chronic autoimmune connective tissue disorder that can affect all the neuroaxes in the central and peripheral nervous systems. Myelopathy in systemic lupus erythematosus is one of the least common neuropsychiatric syndromes accounting for 1%–2% of cases. Myelopathy has long been diagnosed based on clinical findings, laboratory tests, and gold-standard gadolinium-enhanced magnetic resonance imaging (MRI). MRI-negative myelopathy is a recently described subset of myelopathies. Here, we report the case of a young woman from rural West Bengal, India, who presented with overlapping features of white-matter and gray-matter myelopathy associated with peripheral neuropathy and bilateral asymmetric lower motor neuron-type facial paresis. The historical analysis yielded clues toward an etiological diagnosis of systemic lupus erythematosus, further substantiated by seropositivity of lupus-specific autoantibodies. Her neurological disabilities responded poorly to oral administration of hydroxychloroquine, bolus intravenous administration of methylprednisolone, and high-dose cyclophosphamide therapy but eventually responded remarkably well to cyclical rituximab therapy. This case adds to the tally of cases of MRI-negative lupus myelopathy. MRI-negative myelopathy in systemic lupus erythematosus can be easily missed if not meticulous attention is paid during clinical history taking and examinations.

Background: Cancer is a leading cause of mortality in Palestine. The number of cancer cases is increasing, whereas the late stage of diagnosis is common for the majority of cases. Modern diagnostics and medicine are contributing to more positive outcomes for patients when diagnosed early; however, the holistic approach to patient care, patient satisfaction, quality of life (QOL), and survivorship are often overlooked. Patients with cancer are usually treated by physicians and other health professionals employing the “medical model” without considering other factors that might positively affect their treatment. For this pioneering survey, the Functional Assessment of Chronic Illness Therapy-General (FACT-G) tool was used. This study aimed to measure the satisfaction of patients with cancer undergoing outpatient treatments and assess their QOL.

Materials and Methods: The FACT-G scale in Arabic has four sections, measuring physical, emotional, social, and functional well-being, was used in a survey of 203 patients with cancer currently undergoing chemotherapy, radiotherapy, and hormonal therapies. Patients were surveyed in the summer of 2019, within 1 year of diagnosis when they were outpatients, all of whom were attending a major cancer center in a Palestinian hospital.

Results: Emotional well-being scored the lowest (from a total of 24; mean 11.31 (standard deviation (SD) 5.45)) whereas social/family well-being scored the highest (from a total of 28), mean 22, (SD ±  5.78). The overall mean for the four sections was 63.57 (SD 12.44).

Conclusion: To ensure better management of symptoms and treatments, important indicators are now available for health professionals and researchers to learn more about the QOL of patients. Evaluating the physical, social, emotional, and functional states of patients with cancer undergoing outpatient treatments enabled us to learn more about the struggles they face while understanding how they were coping during their cancer journey.