Posted by: notdeaddinosaur | August 21, 2008

Clinical Case: Taste Disturbance, Otitis Externa and Other Symptoms (Part 1)

(Blogged with patient and family permission)

At last! A zebra, of sorts.

70-something-year-old man one week status post coronary stent placement presented with a complaint of two days of severe taste disturbance. He described it as “bitey”; whenever anything touched his tongue — even water — he complained of an acid-like, vinegary taste. All food and drink produced this sensation. There was no oral pain nor pain in the tongue. There was no complaint of dry mouth. On exam the tongue had a faint brownish coating, but nothing else; no inflamed papillae or taste buds were noted. The rest of the exam was completely normal.

The patient was on multiple medications, but the only new one was Plavix, begun after his stent placement last week. Perusal of the PDR revealed a single mention of “taste disturbance” in the Post-Marketing section of the entry for Plavix. At this point my working diagnosis was dysgeusia as an adverse drug reaction to Plavix. Unfortunately, we were unable to stop the drug, so I sent the patient out with instructions to experiment with different foods, flavors and textures to see how he might best cope with this distressing symptom.

Two days later (on a Saturday night) he called complaining of severe right ear pain. He was camping and felt he might have been bitten by some kind of insect, but now the ear was swollen, painful and draining. I met him at the office and discovered that his right pinna was markedly swollen, hot and red. The external canal was swollen shut, therefore I was unable to visualize the tympanic membrane. There was some serous drainage that seemed to be coming from several areas on the antihelix and other parts of the pinna itself. The ear was very tender to touch.

I also noted a small patch of white vesicles on the right side of his soft palate, and perhaps some slight flattening of the right nasolabial fold. The tongue appeared unchanged.

At this point I diagnosed a bacterial otitis externa, probably secondary to a possible insect bite or sting, though I thought it could also have started as a contact dermatitis. I prescribed Augmentin and hot soaks. The lesions on the palate were consistent with Herpes Simplex virus. The patient did have a history of cold sores in the past; frankly I wasn’t quite certain why he now had intra-oral lesions, but I treated him with Valtrex nevertheless.

When I saw him back two days later, the ear was much less red, hot and swollen, though he stated that the pain had not decreased. There was still some serous drainage from areas on the pinna, but I could now see into the external ear canal; it was clear and the eardrum was normal. However he now had a definite right facial nerve palsy: he couldn’t fully close his right eye; the right side of his mouth drooped and there was decreased forehead furrowing on the right. He was also complaining of dizziness, confirmed to be vertigo with careful questioning. In terms of treating the facial weakness (often caused by Lyme disease or a herpes virus) I had already begun Valtrex. I didn’t want to give him steroids with the active bacterial infection in his right ear. I did review eye care, including the use of patching at night and artificial tears during the day. With the evidence of herpes, I did not feel it necessary to rule out Lyme disease.

I saw him again later in the week, and not much had changed. The right pinna, now normal in size and color, was still draining. The Augmentin knocked him for a loop, not unexpectedly, and he had lost a few pounds. The vesicles were now gone from his soft palate. Interestingly, the taste disturbance seemed to be subsiding. I suggested he continue hot compresses and complete the course of Augmentin, as his ear was clearly better, and that he finish the Valtrex.

A few days later, the patient’s daughter called and described a discovery she had made on the internet.

Have at it! (Answer to be posted Monday.)

PLEASE NOTE: Obviously googling the symptoms is cheating, as the diagnosis is easily found. I had never heard of the eponymous condition my patient had and I’m curious about who else has and hasn’t.

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