Lost in Another Language: A Case Report

Husam K. Z. Salamah; Eva Mortier; Renske Wassenberg; Jacqueline J. M. H. Strik

J Med Case Reports. 2022;16(25)

Abstract and Introduction

Abstract

Background: In foreign language syndrome, patients switch from their native language and fixate for a period of time on a second language. There have been few reported cases. The language switch typically occurs postoperatively and spontaneously resolves after a short period of time. The primary cause of this switching remains unclear. There is speculation about the involvement of anesthesia, but its specific influence remains unclear.

Case Presentation: A 17-year-old Dutch Caucasian male lost the ability to understand and speak Dutch for 24 hours after an orthopedic surgery, combined with a brief confused state including disorientation of place and the inability to recognize his parents. During the period, he communicated in English, which he had learned during school classes but had never spoken outside of school. Further follow-up, including neuropsychological examination, revealed no indication of cognitive impairment.

Conclusions: The exact pathophysiology of foreign language syndrome remains unclear, most specifically whether it is a syndrome of its own or a phenotype of emergence delirium. There is still much to be learned, and further research is needed.

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Table 1. Summary of cases of foreign language syndrome
Author	Demographics	Type of surgery	Administered medications	Native language (L1)	Second language (L2)	Outcome	Notes	Author theory/conclusion
Webster [5]	55-year-old Caucasian male (New Zealand)	Pharyngoscopy, inversion of the pouch, and a cricopharyngeal myotomy	Premedication: - Midazolam 2 mg Anesthesia - Propofol 3 mg/kg - Rocuronium 1.2 mg/kg Analgesia: - Intermittent boluses of fentanyl (up to a total dose of 1.5 μg/kg) Prophylactic: - Augmentin 1.2 g	English	- Spanish (working knowledge) - Started learning at the age of 37 years - Spoken yearly due to his visits to Chile	- Initially Spanish speaking; understood English and Spanish - Recovered English-speaking ability in 1 hour after sleeping	- Recalled the event and the frustration of not being able to think of an English reply - Did not remember any specific details of what he said in Spanish	- Native and non-native languages are stored in spatially separate areas in the brain - Anesthetics affect the areas differentially, so one language faculty remains active while the other is inactive - Hypoglycemia could be associated - In this case, unclear whether the patient was hypoglycemic at the time of his transient fixation episode
Pollard [6]	64-year-old Caucasian male (from USA)	Bladder cancer presented for radical cystectomy	- Opioid for pain control. Anesthesia: - Propofol (maintained with volatile agents and fentanyl)	American English	Norwegian	- Norwegian Speaking only postoperative - Recovered English-speaking in 5 hours		- Assumption that the event transiently affected L1 area of the brain (English) and spared L2 region (Norwegian) - Only males; possible explanation is lateralization of languages in males (left-dominant activation)
Ward [18]	54-year-old Caucasian male (England)	Arthroscopic surgery for medial meniscectomy	Premedication: - Ranitidine 150 mg - Metoclopramide 10 mg Anesthesia: - Midazolam 2 mg - Propofol 180 mg - Fentanyl 75 mg Other: - Diclofenac suppository 100 mg (inserted rectally)	English	Spanish	- Initially Spanish speaking - Recovered English-speaking once glucose replenished	- No recall of speaking Spanish - Second time speaking Spanish after surgery with general anesthesia - Denied being able to speak it any longer	Suppression of a mother tongue leading to the release of acquired language Possible explanations: - Hypoglycemia: a temporal lobe seizure was induced by hypoglycemia and postictal period speech was depressed, allowing the learned speech to emerge - Anesthesia, resulting in significant cerebral insult - Parapsychology
Cosgrove [19]	Male in his 70s, undocumented race	An open reduction and internal fixation of a fractured tibia	- Fentanyl - Propofol	English	Hindi (learned some phrases in army during World War II)	During the induction, when counting aloud to 30, he began in English and then continued in Hindi	Denied being able to remember or speak Hindi	Language switching due to general anesthesia
Akpek [20]	68-year-old Caucasian male (Czechoslovakian, living abroad)	Unknown		Czechoslovakian	English	- Did not understand English commands - Recovery time not documented		- Main language is primarily stored in "implicit memory systems" of the subcortical regions - Acquired languages stored more diffusely in the cerebral cortex - The role of anesthesia is not yet understood
Akpek [20]	Male of undocumented race and age (from Turkey, lived in USA)	Unknown		Turkish	English	- English-speaking only postoperative - Recovered speaking Turkish within 24–28 hours
Yulia Ivashkov [21]	52-year-old Caucasian male	Elective ankle osteotomy for a malunited tibial fracture		English	French (learned some from his mother who was a native French speaker)	French speaking postoperatively, recovered English-speaking in 1 hour	- Did not recall speaking French during his recovery from anesthesia - Remembered his frustration when everybody was "speaking Russian" and not being able to understand - This was possibly a mistake due to hearing an anesthetist speaking English with a Russian accent	Speech suppression could either (a) be produced by anesthetic agents or (b) be a consequence of other cerebral events of an ischemic nature (embolic or otherwise)
Yulia Ivashkov [21]	28-year-old Caucasian male	Right orbital floor blowout fracture was undergoing a fracture repair	- Midazolam - Fentanyl - Propofol - Rocuronium - Maintained with sevoflurane	English	Spanish (studied in primary school but had never used it)	- Understood English and could follow commands but responded in Spanish - Recovered in 25 minutes postoperation	- Had had several similar episodes of conversion to Spanish in the past during occasions of severe alcohol intoxication - The intoxication events had required an emergency medical response, and the medical personnel had noted that he had spoken fluent Spanish during these episodes
Our case	17-year-old Caucasian male (the Netherlands)	Cartilage repair lateral femoral condyle right	Anesthesia during surgery: - Sufentanil 35 mcg - Morphine 4 mg - Propofol 290 mg + propofol 928 mg 10 mg/ml - Cefazoline 1000 mg - Efedrine 7.5 mg - Paracetamol 1000 mg - Dexamethasone 4 mg - Ondansetron 4 mg - Tranexamic acid 375 mg - Ringer's lactate 1000 ml	Dutch, southern dialect (Limburgish)	English (acquired in a nonbilingual school during regular English classes)	- Initially English-speaking and did not understand Dutch postoperatively - Recovered English-speaking after 24 hours	In the beginning, was confused and was unaware he was speaking a non-native language	FLS as phenotype of ED

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Lost in Another Language: A Case Report

Abstract and Introduction

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