Watershed infarction during the first favism crisis in a Syrian child; A rare case report

Background: A watershed infarction is an ischemic event within the border zone regions of the brain. It can be associated with hematologic disorders including beta thalassemia and sickle cell disease. However, it has not been reported during a favism crisis. G6PD deficiency is an X-linked recessive genetic disorder and one of the most prevalent enzyme deficiencies in humans, with a global prevalence of 4.9%. The most common triggers for hemolytic crises in G6PD deficiency are fava bean ingestion, infection and specific medications. We describe a rare case of a 3-year-old boy who developed a watershed infarction during his first favism crisis — an association has not previously reported. Case Presentation: A 3-year-old male was admitted to our hospital with an acute hemolytic crisis (with a hemoglobin level of 3.3 g/dL) triggered by fava bean ingestion. After 6 hours of admission the patient developed neurological symptoms with normal vital signs and no hypotension. After several investigations, bilateral watershed infarction was confirmed by Magnetic Resonance Imaging. Fluid resuscitation and blood transfusion with intensive care were sufficient to improve the neurological symptoms and elevate hemoglobin level above 10 g/dL. The patient was discharged after 9 days of admission with full recovery. Conclusion: According to our acknowledgement, this is the first reported case of watershed infarction triggered by favism, thus we aim to highlight the importance of accurate and frequent neurological examination for hemolytic crises patients to prevent adverse complications of delayed treatment.