Cases That Test Your Skills

Something smells different

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Ms. D, age 69, has a history of bipolar II disorder and presents with new symptoms, including weakness and increased falls, and smells noxious odors. What could be causing these symptoms?



CASE: Depressed and hopeless

Ms. D, age 69, has a 20-year history of bipolar II disorder, for which she is taking citalopram, 30 mg/d. She presents to her outpatient psychotherapist with a chief complaint of depressed mood. The therapist refers her for psychiatric hospitalization and electroconvulsive therapy consultation. Upon admission, Ms. D reports that her depressed mood has worsened over the past 5 weeks after a trip to the Dominican Republic. Ms. D had a negative encounter with airport security that she attributed to her 2 artificial knees and caused her to miss her flight. She endorses poor appetite, loss of energy, anhedonia, difficulty concentrating, poor memory, and feelings of hopelessness.

Ms. D reports increasingly frequent panic attacks as well as intermittent right-sided discomfort, unusual noxious smells, and increased falls. She says the falls likely are a result of new bilateral lower extremity weakness coupled with long-standing imbalance. Ms. D says she has experienced brief occasions of foul-smelling odors while showering without evidence of an offending substance. She also reports a mild, occipitally located headache.

Four years ago, Ms. D was hospitalized for a depressive episode without psychotic features and diagnosed with generalized anxiety disorder, for which she is taking clonazepam, 1.5 mg/d. Her last hypomanic episode was several years ago, and was characterized by increased energy with decreased need for sleep, flight of ideas, increased productivity, and impulsivity. Her medical history includes non-insulin dependent diabetes mellitus, chronic low back pain, hyperlipidemia, arthritis, and gastroesophageal reflux disease; her medications include pioglitazone, 30 mg/d, oxybutynin, 15 mg/d, rosuvastatin, 20 mg/d, losartan, 50 mg/d, and omeprazole, 20 mg/d. She also had bilateral knee replacements 9 years ago and an L4-S1 spinal fusion 11 years ago. She has no history of head injuries or seizures. Ms. D’s father had major depressive disorder, her mother died of a cerebrovascular accident at an unknown age, and her brother died of a myocardial infarction at age 52.

The authors’ observations

A striking aspect of Ms. D’s presenting complaints was her intermittent experience of foul smells. Although olfactory hallucinations can occur with psychotic and affective states, they also may be harbingers of an organic etiology involving the temporal lobe.1 Olfactory hallucinations associated with a psychiatric disorder often have an accompanying delusional belief regarding the cause of the smell.2

Olfactory hallucinations have been associated with migraines, epilepsy, and Parkinson’s disease.1-3 Neoplasms, cerebrovascular events, or traumatic brain injuries that result in focal mesial temporal lobe lesions can present as a partial complex seizure with olfactory or gustatory hallucinations and progress to automatisms.4 Characteristic odors in these hallucinations are unpleasant; patients with temporal lobe epilepsy describe the smells as “bad,” “rotten,” “sickening,” and “like burning food.”2 Ms. D’s report of unusual smells warranted consideration of an organic etiology for her mood change and a thorough neurologic examination.

EVALUATION: Neurologic signs

At the time of admission, Ms. D has a blood pressure of 127/68 mm Hg, heart rate of 74 beats per minute, respiratory rate of 16 breaths per minute, and temperature of 36.5°C. Neurologic examination reveals a left facial droop of unknown duration. Motor strength is weak throughout with left-sided focal weakness. Ms. D’s daughter notes that her mother’s smile appears “funny” in her admission photograph but is unsure when the asymmetry in her facial appearance began. Ms. D had been ambulatory before admission. Nursing staff observes Ms. D leans toward her left side and exhibits possible left-sided neglect during the first 12 hours of hospitalization.

When asked about her facial droop, Ms. D replies that she had not noticed any change in her appearance lately. She does not appear to be concerned about her worsening ambulation. On hospital day 2, Ms. D seems to have difficulty using utensils to eat breakfast. Ms. D is dismissive of her worsening motor function and asks to be left alone to finish her meal.

The authors’ observations

Ms. D’s focal neurologic deficits and complaint of a headache on admission were concerning because they could be caused by a cerebrovascular event or space-occupying brain lesion with potential for increased intracranial pressure. Neurologic examination with evaluation for papilledema is indicated, followed by medical transport to the closest medical center for emergent brain imaging. Neither Ms. D nor her daughter could pinpoint the onset of Ms. D’s left-sided facial droop, which precluded administering tissue plasminogen activator for a potential acute ischemic stroke.5

Ms. D’s case prompted us to consider what constitutes timely brain imaging in a patient who presents with psychiatric symptoms. Several neurologic conditions may present first with neurobehavioral symptoms before findings on physical exam. Two series of autopsies conducted >70 years ago at psychiatric hospitals found incidences of brain tumors of 3.45%6 and 13.5%.7 In a 5-year retrospective study, 21% of meningioma cases presented with psychiatric symptoms alone.8 These historical cases suggest that affective, behavioral, and psychotic symptoms may be the only clinical indicators of brain lesions that merit surgery.9-11

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