Discussion:
Severe acute respiratory syndrome coronavirus-2 (SARS-COV-2) is very
contagious, that why it spread rapidly around the world since the end of
2019 causing the most recent respiratory pandemic in our century.
History that might reveal exposure risk for diagnosed cases as well
clinical manifestations plays an important role in the suspicion and
thus diagnosis cases and controlling infection spread. Diagnosis
confirmation is mainly via reverse transcriptase chain reaction (RT-PCR)
though it has 30% false negative rate. Clinical manifestations might
vary widely. However, the most common ones are fever, fatigue, headache,
and myalgia. Gastrointestinal symptoms were considered less
common[1]. Other atypical presentation like anosmia (Loss of smell),
Agnosia (Loss of taste) were reported before[3].
The impact of coronavirus on pregnant women is not clear till today.
However, some studies consider pregnancy as vulnerable state and viral
infections might increase morbidity and mortality in the mother as well
her fetus yet no evidence to our date that pregnancy increases COVID-19
susceptibility and risk of COVID-19 complications[1]. During
pregnancy the symptoms were as described among non-pregnant patients.
However, our patient has smooth course of infection and normal delivery
without complication. Cacosmia was the only persistent symptoms that
cause her nausea and few times vomiting during the second and third
trimester which obviously affected her psychologically and nutrition.
Recent European study observed the ENT presentation of COVID-19 and
found that olfactory and gustatory dysfunction are quite common with
olfactory dysfunction occurring in 85.6% and gustatory dysfunction in
88% [2]. Another study showed that olfactory loss or anosmia occurs
in 39% following upper respiratory infections with a return to normal
rate that varies depending on multiple factors like the patient age,
gender and if the baseline disorder is hyposmia or anosmia [4].
Thus, anosmia was suggested to be one of the diagnostic criteria
especially in the presence of other symptoms, and most of the patients
that were included of this study described that changing on taste and
smell happened after other symptoms rather from the beginning.
[5,6].However, Cacosmia which happened in our patient was note
prescribed in the previously published studies.
Olfactory disturbances are classified into three categories: first,
Hyposmia and anosmia which mean decreased sensitivity. Second, odorant
stimulation disorders where there is a distortion in the perceived odor
(Troposmia), and third, smelling hallucination where the odor is mostly
unpleasant (phantosmia), unpleasant phantosmia sometimes called
cacosmia. Usually the distortions on the smell is the most upsetting
symptoms to the patients and remarkably affects their quality of life
among these disturbances. Etiology behind this disorder is not clearly
defined but it can be categorized into central and peripheral. Central
etiologies or combination of both[7].
To the best of our knowledge, no previously published articles about
cacosmia, thought other olfactory disorders like hyposmia and anosmia
have been clearly described. Our patient had the gustatory and olfactory
symptoms from the beginning. The persistent of hyposmia and cacosmia
mainly was very irritant to her, giving her unpleasant feeling during
her second and third trimester and causing persistent nausea. By
excluding other possible diagnosis, persistent of complain after
delivery, not responding to specific treatments, all of these factors
made us correlate the patient complain to COVID-19 especially on the
absence of similar episodes before the infection. We believe that
physician should be aware of the ENT presentation of COVID-19 including
ageusia and anosmia as well considering cacosmia in COVID-19 patients.
Whether pregnancy has a role on the prolongation of this atypical
symptoms or not is something that needs further research. Physician as
well should take into account the implication of cacosmia on the
pregnant women due to the physiological impact and the affect on the
nutrition which might indeed affect the pregnancy.