Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Thursday, 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.

14 Comments:

At Thu Aug 21, 08:13:00 AM, Blogger Lancelot Gobbo said...

Ramsay Hunt strikes again!

 
At Thu Aug 21, 08:36:00 AM, Blogger Philly P said...

I'll go with some kind of shingles /zoster along CN VII, based both on symptomatology and your persistent mensioning that the patient was *already* started on valtrex.

Looks it up ...

Pretty close!

 
At Thu Aug 21, 11:48:00 AM, Blogger Jane said...

Shingles? A friend had something similar.

 
At Thu Aug 21, 11:50:00 AM, Blogger R. W. Donnell said...

I'd go with Ramsay Hunt. It looks like your first commenter beat me to it. THe swollen ear may have been a secondary bacterial infection.

 
At Thu Aug 21, 05:32:00 PM, OpenID Teendoc said...

Sounded like a Bell's Palsy but I couldn't place the HSV lesions. I just learned something new.

 
At Thu Aug 21, 11:30:00 PM, Anonymous Anonymous said...

Ramsay-Hunt.

 
At Fri Aug 22, 12:01:00 AM, Blogger The R.N. formerly known as Angry Male Nurse said...

Awesome medical stylings.

Good stuff!

 
At Fri Aug 22, 08:12:00 AM, Blogger Ninja Medic said...

Ramsay Hunt. I only know this 'cause a girl I knew got it after giving birth. She was miserable for weeks....

 
At Fri Aug 22, 09:54:00 AM, Blogger Lynn Price said...

No fair, Dino, I only write about docs, I don't know from nuthin', and you're going to make me wait 'til Monday? Cruel, cruel doc. I'll exact my revenge...I'm going to insert a new character in Chap. 17 - the evil Dr. Dino. Bwhahahaa

 
At Fri Aug 22, 02:30:00 PM, Anonymous chfamilydoc said...

I've been reading this blog for a while - and I'm shocked you've never heard of this and couldn't make the diagnosis until the patient's daughter located it. He should have been started on steroids on second visit. I bet there'd be an angry dinosaur story if the daughter called and didn't make the right diagnosis, but Googled something weird instead, eh? I hate when my patients Google catastrophic zebras, but I guess this is why, if we have doctors who have never heard of Ramsay-Hunt

 
At Fri Aug 22, 02:36:00 PM, Anonymous chfamilydoc said...

Also, as I'm sure you learned in the first two years of medical school, you look for a diagnosis that explains all symptoms, not a separate one for each. If you didn't know, you should have called a colleague to discuss, or (gasp!) a specialist.

 
At Sun Aug 24, 08:30:00 AM, Blogger ohn said...

Wow chfamilydoc sure woke up with his/her cranky pants on.

 
At Sun Aug 24, 04:08:00 PM, Blogger Resident Anesthesiologist Guy (RAG) said...

Well I've never heard of Ramsay-Hunt either...guess I'm a failure as well, eh CHfamilydoc? Ass.

 
At Sun Aug 24, 11:30:00 PM, Anonymous Anonymous said...

Diagnosed Ramsay-Hunt syndrome from the title of the post. Confirmed by the precise case report that followed.

It's not uncommon. Just don't mistake it for Bell's palsy.

James Wilk, MD
Denver

 

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