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24 CerefolinNAC Therapy-Induced Dysgeusia
- Jasir T. Nayati, Fizah S. Chaudhry, Tajinder Parhar, Ather M. Ali, Alan R. Hirsch
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- Journal:
- CNS Spectrums / Volume 24 / Issue 1 / February 2019
- Published online by Cambridge University Press:
- 12 March 2019, p. 186
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Introduction
CerefolinNAC (CFLN-NAC) is a prescription medical food reported to help with mild to moderate cognitive impairment [Pamlab 2017]. It contains L-methylfolate calcium (6mg), methylcobalamin (2mg), Schizochytrium (90.3mg), and N-acetylcysteine (NAC) (600mg) [Pamlab 2017]. However, dysgeusia secondary to CFLN-NAC therapy has not heretofore been described.
MethodsA 64 year-old female presented with an eight year history of progressively decreased ability to smell and taste of unknown origin. CFLN-NAC was prescribed off-label to treat her hypogeusia and hyposmia. Three days after treatment initiation, her taste sensations gradually returned and she was able to describe food as bitter, salty, sour and sweet. Also, she was able to decipher the taste of different nuts, such as almonds, macadamia, pecans, and peanuts at baseline. However, her taste sensations became distorted and she was unable to distinguish specific foods. She reported that most food tasted bland, but she was still able to sense textures of various foods describing them as, “crunchy, but without taste.” She denied any oral pain, xerostomia, hot flashes, and psychological distress. CFLN-NAC was continued for three months and her hypogeusia improved from 20% to 80%. Her dysgeusia persisted, but remitted once CFLN-NAC was discontinued.
ResultsAbnormalities in physical examination: General: scalloped tongue, decreased blink frequency, and hypokinesia. Cranial Nerve (CN) Examination: Olfaction (CN I) Testing: Alcohol Sniff Test: 8 (hyposmia). Pocket Smell Test: 2 (hyposmia). Olfactometer Identification Test: Left: 5 (anosmia); Right: 12 (hyposmia). CN III, IV, VI: saccadization on horizontal eye movement. Motor Examination: hypokinetic movements and 1+ cogwheel rigidity in bilateral upper extremities. Drift Test: bilateral abductor digiti minimi signs with cerebellar spooning. Reflexes: absent patellar and Achilles bilaterally. Hoffman’s Reflex: present bilaterally. Other: Magnetic resonance imaging (MRI) of the brain with contrast was unremarkable.
ConclusionWhen treating taste impairments, vitamins and minerals have been found to enhance the effect of non-injured nerves, but they do not repair damaged nerves. The presence of a scalloped tongue may suggest nerve injury of unknown proportion, and can either diminish or alter taste. CFLN-NAC may have enhanced the gustatory stimulus of the non-injured nerves. This transient increase could have either caused her dysgeusia or possibly unmasked the dysgeusia secondary to a scalloped tongue. Notable impairments found in her exam evince Parkinson’s disease as a possible etiology, but structural abnormalities were not seen on brain MRI, making this unlikely. Conversely, the relatively rapid resolution after terminating CFLN-NAC strongly suggests that this is not merely a coincidence, but rather an origin. Those initiated on CFLN-NAC should be queried for new onset of dysgeusia and warrant other treatment options.
Funding Acknowledgements: Smell & Taste Treatment and Research Foundation
25 Ventriculoperitoneal Shunt as a Meteorologist: Medtronics Shunt Headaches Vaticinating Climatic Perturbation
- Jasir T. Nayati, Syed Mohyuddin, Tajinder Parhar, Ather M. Ali, Alan R. Hirsch
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- Journal:
- CNS Spectrums / Volume 24 / Issue 1 / February 2019
- Published online by Cambridge University Press:
- 12 March 2019, pp. 186-187
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Introduction
Neurological conditions can be influenced by meteorological parameters. Some may predict weather changes, such as migraines [Marrelli 1988], burning mouth syndrome [Hirsch 2017], phantosmia [Hirsch 2013], and Bell’s Palsy [Danielides 2001]. However, climatic conditions inducing headaches in those with ventriculoperitoneal shunt (VPS) placements have not heretofore been described.
MethodsA 46-year-old female presented with epochs of headaches coinciding with climatic changes. She had hydrocephalus secondary to infantile meningitis that was treated with a Medtronics Strata II adjustable VPS. After multiple revisions, she noticed a headache occurring only before thunderstorms or snowstorms. These headaches were constant, bilateral, “halo-like” downward pressure located only around her parietal regions. It persists all day and does not dissipate after onset, regardless of the storm passing. She rates it 8/10 on the pain scale, and is exacerbated by jarring, sneezing, and bending forward. It is only alleviated with acetazolamide, diminishing to 0/10. She denies any pain relief when supine, pain radiation, rhinorrhea, auras, or correlating psychological distress.
ResultsAbnormalities in physical examination: General: hammer toes. Neurological Examination: Cranial Nerve (CN) Examination: CN III, IV, VI: saccadization on horizontal eye movement and bilateral ptosis (left > right). CN IX, X: right uvula deviation. Motor Examination: left upward-outward drift with a positive left abductor digiti minimi sign. Reflexes: 3+ bilateral biceps, brachioradialis, and patellar; 3+ right tricep and 4+ left tricep. Hoffman's Reflex: positive bilaterally (left > right). Neuropsychological Tests: Mental Status Examination: Recent Recall: 1/4 objects in three minutes without improvement with reinforcement. Go-No-Go Test: 6/6. Animal Fluency Test: 21 (normal). Center for Neurologic Study-Lability Scale: 23 (pseudobulbar affect).
ConclusionHow climatic changes induce VPS headaches remains unclear. Barometric changes have been reported to cause sinus engorgement [Kaliner 2009], somatic pain [Silove 2006] and can worsen anxiety and depression [Delyukov 1999]. Meteorological parameters may have induced or exacerbated her depression and anxiety, amplifying pain perception. Alternatively, barometric pressure can cause an increase in other somatic pains and stresses, which can augment awareness of additional, unrecognized somatic pains. It is also possible for barometric pressure to cause pain via nasal sinus or mucosal engorgement; thus, mimicking her VPS headache. Lastly, however unlikely, her pain may be a result of a transient VPS malfunction. The mechanism for such can be attributed to transient pressure changes caused by fluctuating blood pressure, inducing brief intrinsic intraperitoneal pressure changes. Nevertheless, querying patients suffering from VPS headacheswhether climatic changes play a role in their symptoms is warranted.
Funding Acknowledgements: Smell & Taste Treatment and Research Foundation