When fragrance becomes a disease

When fragrance becomes a disease

Vijay Gopichandran

Imagine feeling sick every time you come across a good fragrance. When the powerful smell of freshly bloomed jasmine hits the nostrils, she felt sick and vomited. When the pleasant aroma of cashew nuts being fried in butter swifts down the kitchen, she felt like vomiting. Every good, strong smell made her sick. Mrs. Thangam is a 45 years old lady, who came to the clinic today complaining of an intense sick reaction with headache and vomiting whenever she smelt something strong. I knew of a cousin of mine who got bad headaches where room freshener was sprayed or when one of us wore body spray. All kinds of fragrant objects were banned in her house. But this is a condition she had right from her childhood. She was brought up with no strong fragrances in her home. Soaps were mild, shampoos were mild, there was even no agarbatti in their home during worship. But this patient was not like that. She had a recent onset exaggerated sick reaction to smell just over 2 weeks duration. I was wondering what the reason could be. 

One of the commonest reasons for such an exaggerated and abnormal reaction to strong smells is pregnancy. So, I asked her about her last menstrual period. She said she had recently had her periods and it was regular. So, this was unlikely to be pregnancy-induced. There are other rare and uncommon causes of this condition known as hyperosmia. Migraine is a condition where there is a heightened sensitivity of the blood vessels in the brain and they lead to severe headaches. Sometimes migraine can be precipitated by strong smells. Such migraine attacks have an early age onset. They rarely start in a person when they are in their mid-40s. 

Some disease of the immune system, which lead to abnormal attack by the immune defense system against the body’s own tissues, also known as autoimmunity, such as in Systemic Lupus Erythematosus, can lead to hyperosmia. Other rare causes of such new-onset hyperosmia can be tumors of the frontal lobe of the brain, Alzheimer’s disease, Parkinson’s disease or epilepsy. All these conditions are very rare to present as hyperosmia alone, without any other manifestations. So, I was not sure what I was handling in this lady. 

It took me a lot of time to grasp the gravity of the situation that this woman was suffering from. My first response to her complaint was, “What a strange complaint? There are many people who are intolerant to strong smells. Why would people choose to see a doctor about this?” But then as I interacted with her trying to understand her, I could see lines of serious worry and concern on her forehead. If someone always had trouble tolerating strong smells, they would stay away from them. I know how my cousin (the one who is intolerant to strong fragrances) reacts when she finds any of us wearing body spray. She literally throws a fit and chases us out. The self-protection reflexes are strong, and they develop over time. But this lady must have been taken completely by surprise. She has developed this hyperosmia over a very short period. The intensity of her sickness to strong smells must have completely disturbed her. Till a few weeks ago she liked the pleasant fragrances which most of us enjoy occasionally. But when the same smells which gave you pleasure, now give you such intense pain and suffering, it must be really freaking her out. I slowly understood that the lines on her forehead are because of the fear and apprehension that she must be experiencing. 

As a doctor, I learned a very important lesson today. I learned that it is not just enough for me to listen to a patient’s complaints, interpret it and make clinical sense out of it. I understood that there are deep-seated important clues behind every word, gesture, and act of a patient. the very fact that she came to a hospital for a seemingly trivial complaint rang the first alert bell. Then, the high degree of apprehension and fear that this woman had about becoming sick to strong fragrances provided the second alert. The dramatic and sudden nature of her history topped up the story with just the right amount of alarm. Unless I pay attention to these subtle clues in the clinical encounter, I would have dismissed this as another medical unexplained somatic complaint. Now, I will carefully evaluate and follow her up for the different conditions that I have mentioned above. 

Once again, the clinical encounter with this woman helped me see the importance of careful attention to the details in history. I will update this clinical blog with the follow up on this lady. 

Meanwhile, I have some interesting updates on the young man I wrote about in my blog titled “The Power of Privacy”. The young man, accompanied by his overpowering mother, had post encephalitis sequelae and slow cognitive functions. So, he was having low self-esteem as his work performance was affected by his slow cognition. He was sleep-deprived and had a poor appetite because of depression and anxiety. I had started him on anti-depressants. Today he came back. He looked far more cheerful. He said he had started sleeping and eating well. He said he is still feeling tired and unable to perform his work very well. But he was feeling much better. His mother was there with him again today and she said, “what to do doctor? I have spent so much money on him so far. Still no use.”. I wish I could have told her something rude and shut her up. My colleague who saw him, also felt that it would have been better if the guy had come alone and we could have had an open talk with him again today. We are continuing his medications today and hope he slowly starts feeling even better than now. 

On our way back home this evening, my colleague asked me a very important question. She asked, “In all your blogs you try and bring a philosophical message. What is the message from the story of the patients with hyperosmia?” I couldn’t answer her then. Now I think, I have an answer. The philosophical message from the story of Mrs. Thangam is that, when something looks trivial, look closely and look carefully. Sometimes the most trivial things harbor deadly puzzles. A simple hyper-responsiveness to strong smells can hide some ominous neurological conditions within it. It is always useful to be observant, perceptive, intuitive and vigilant.