27. The Anosmia
‘Not everything is what it seems, Lisa.’
‘What do you mean?’ I was not getting Lucy's point.
‘You’re missing the big picture. You need to think about other hypotheses. Figure it out and let me know when you do.’
I honestly had no idea what she was talking about. It seemed a pretty straightforward case to me. I waited for her to leave to ask Peter if he had any ideas.
‘Don’t know, Lisa. We are missing something. Present the case to me again.’
‘57-year-old female, Janice Lieberman, with a long history of poorly controlled diabetes already with kidney damage, came to the hospital with a complaint of otalgia, hearing loss, nasal discharge, and anosmia for a few weeks. She took some antibiotics by herself but they didn’t work. She underwent a CT scan that confirmed sinusitis and even showed bony erosions. The purulent discharge seemed fungal and was sent to culture, while we started Amphotericin B.’
‘That’s it?’ Peter asked.
‘Yep.’
‘Damn. It does seem a pretty straightforward case of mucormycosis in a diabetic patient.’ He laughed.
‘Tell me about it. What am I missing?’
‘Does she have any other symptoms?’ I shook my head. ‘Weight loss, fever, rash?’
‘Rash?’ I asked, wondering what was on his mind.
‘I’m guessing here, Lisa.’ He shrugged. ‘At least I’m giving some ideas, aren’t I?’ Haven’t heard any of those coming from you, and it’s not even my patient.’
‘Alright, alright, sorry. This case is bothering me.’
‘I know, nerd.’
Peter left to take care of other matters involving his patients and I stayed there for a while thinking about Mrs. Lieberman. It’s so hard to think of other differentials when the diagnosis is already there in front of you, the full package. I can think of a billion causes for abdominal pain, but for right lower quadrant pain with a positive Blumberg sign, how do you stop thinking of appendicitis?
I went to talk to her again, and she reassured me that she wasn’t having any other symptoms.
‘But I already had this before, my dear. Sinusitis.’
‘Very annoying, isn’t it?’
‘You have no idea!’ She sighed. ‘It’s almost as bad as not being allowed to eat sugar.’ She laughed.
‘You like sweets?’
‘Love them! But now I can’t even smell the sugar so the fun is gone.’
‘Well, at least it’s easier to resist them now, isn’t it?’
She smiled.
‘You do have a point there.’
After that, I decided to call the nephrology resident to know what they were thinking about her kidney failure, and he told me he thought it was from diabetes but his attending was not so sure about it. Either way, they hadn’t discussed her case yet. Bummer.
I needed to refresh my mind, so I went for coffee and a walk outside. It was a beautiful warm day, one of the nicest I’d seen in a while. It felt good and I could smell the grass at the hospital entrance.
That reminded me of Janice. She couldn’t smell anything, and that was what was bothering her the most. It’s a more disturbing symptom than it seems actually. It really messes with your taste. And she was feeling like that for almost a month now.
When I thought about that, I realized that the timing didn’t really fit. Mucormycosis was usually very serious and deadly, especially in diabetics. How come she was still stable?
I came back inside happy to have finally thought of something that didn’t fit to point me towards another diagnosis. On my way back, I found Peter in the hallway.
‘The timing!’
‘Sorry, are we playing some kind of word game I’m not aware of?’
‘I’m talking about Janice. Her timing doesn’t fit! Mucormycosis is deadly and she is completely stable with these symptoms for almost a month now.’
‘Interesting.’ He walked towards me. ‘What are you thinking?’
‘So far, only what I just told you.’ I laughed.
‘Well, maybe you’re right, and it’s not infectious. And if that’s the case, and she has chronic sinusitis...’
‘Wegener. Yes, it could be Wegener. But how likely is it that she only has sinusitis as a symptom?’
‘Does she? Didn’t you say she had a kidney problem?’
‘Yes, from diabetes.’
‘How do you know it’s from that?’
I thought about it for a moment.
‘Damn. I don’t.’ I remembered my call with the nephrology resident. ‘In fact, she doesn’t have retinopathy or peripheral neuropathy, which would be expected if the diabetes was affecting her kidneys. Besides, she does have a weird-looking chest x-ray.’
‘Well, then you know what she needs.’ He smiled. ‘Order a c-ANCA for Mrs. Lieberman.’
And wasn’t Dr. Collins right, not everything is what it seems. Janice had Granulomatosis with Polyangiitis (aka Wegener’s Granulomatosis). We began treatment with corticosteroids and cyclophosphamide and she got better.
It is like they say, sometimes in medicine, it looks like a pig, it smells like a pig and it even sounds like a pig, but it’s not a pig.
…
Want to read more about Granulomatosis with Polyangiitis?
https://rarediseases.org/rare-diseases/granulomatosis-with-polyangiitis/
Want to read a real case of Granulomatosis with Polyangiitis?
https://www.jabfm.org/content/16/6/555
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