First-episode olfactory hallucination in a patient with anxiety disorder: A case report

Case Presentation

A 66-year-old woman was admitted to the hospital due to olfactory hallucination.

In 2004 the patient had been admitted to the hospital due to insomnia and nightmares.
She had difficulty in initiating sleep and frequently awakened almost every night.
She was diagnosed with insomnia disorder
In 2017 she gradually manifested olfactory hallucinations, claiming that she could smell some Chinese medicines, even in wide open spaces on mountains.
When the patient was admitted to the hospital in 2021, she reported that 6 months before, her olfactory hallucinations had worsened and that the phantom smells had changed to something like a mixture of scallion, ginger, and garlic.
At the same time, she reported being unable to smell normal scents, being unable to fall asleep at night, feeling restless and fatigued, having difficulty concentrating on daily activities, and often feeling limb muscle tension and sweating.
She worried a lot about her daughter’s marriage, feared and that some accidents would happen to her family members.
She had a history of tuberculosis and cholecystectomy and has also been diagnosed with hyperlipidaemia

Endoscopy failed to reveal obvious structural auxiliary abnormalities or abnormalities in the nasal cavity or nasopharynx.
Axial and coronal computed tomography of the nose showed only paranasal sinusitis.
Brain magnetic resonance imaging only showed a few ischemic foci in the brain parenchyma and paranasal sinusitis.
Chest computed tomography showed soft tissue nodules in the anterior basal segment of the lower lobe of the right lung, while both lungs showed multiple, scattered, small inflammatory nodules as well as mild chronic inflammation.
Bilateral pleural thickening and adhesion, enlarged mediastinal lymph nodes, and aortic wall calcification were also observed
Hamilton anxiety rating scale (HAM-A) score was 22

The patient was treated with paroxetine (20 mg/day), tandospirone (10 mg three times a day), and lorazepam (0.5 mg/night) to relieve anxiety and control sleep disorders, as well as atorvastatin calcium (5 mg/night) to control hyperlipidaemia.
After 4 days of this therapy, the patient started to smell a strong odour of ammonia in the restroom, especially in the afternoon. Therefore, medication was adjusted to tandospirone (10 mg three times a day), paroxetine (40 mg/day), and lorazepam (0.25 mg/noon and 0.5 mg/night).
After 6 days on the modified drug regime, the patient claimed that the odour became mild, but she still had hyposmia for normal smells, especially in the afternoon.
After 10 days on the physiotherapy and modified drug regime, the patient reported feeling relaxed and sleeping well at night, with no olfactory hallucination.

At a 3-month follow-up, she reported no olfactory hallucination, and she slept well.

All positive symptoms disappeared completely, but negative symptoms persisted.