A Rare Case of Fish Odor Syndrome Presenting as Depression

Article excerpt

Byline: Shahbaz. Khan, K. Shagufta

A young lady presents to the psychiatry out-patient department with depressive symptoms. Evaluation revealed long standing stressor in the form of a foul odor emanating from her body and over a period of time resulting in social withdrawal and depression with significant impairment of day-to-day functioning. A diagnosis of trimethylaminurea (fish odor syndrome) and adjustment disorder was arrived at. Careful empathetic handling with psychoeducation, behavioral and cognitive counseling and a short course of antidepressants helped her improve significantly with return to almost normal functioning.

Introduction

Triemthylaminuria, a rare genetic disorder also known as "fish odor syndrome" is a disorder of amino acid metabolism, caused by the deficiency of enzyme flavin containing monooxygenase (FMO). [sup][1] It is an uncurable condition and is characterized by a foul putrid smell emanating from the body, which can be socially repulsive and personally demoralizing. The presentation may not be direct to a physician, but indirectly as depressive symptoms to a psychiatrist. One such case is described here where a young unmarried girl was brought to medical help by her mother in a suicidal state after prolonged suffering in ignorance. Uninterrupted, her suffering might have naturally progressed to severe dysfunction and possible suicide. Psychiatric intervention mainly by empathetic, supportive, behavioral and cognitive psychotherapy helped her regain confidence and an acceptable level of functionality in socio-academic sphere.

Case Report

This was a case report of a 20-year-old unmarried female patient who reported to psychiatry out-patient department accompanied by her mother. The presenting complaints were irritable mood, not taking interest in household chores, not socializing with friends and colleagues and dropped out of college for last 6 months.

During the course of the interview, a peculiar putrid smell filled the air and on direct questioning in the next interview the mother gave h/o rotten ("intolerable") vegetable smell emanating from her body. Although the odor was present since adolescence it was more noticeable since the last 2-3 years. The smell increased in summers and winters were a shade better. She had increased odor during the menstrual periods and after games/physical exertion, more toward the evening. The intensity was overall waxing and waning in time. In an attempt to avoid criticism and ostracization she had receded in her social interactions. Over the last 6 months she had become irritable, easily moved to tears and anger in the house, lost interest in studies and refused to participate in the household chores. She stopped going to college and had got herself enrolled in a graduate correspondence course.

Personal history revealed uneventful childhood with no h/o abuse/trauma or separation from parental figures. She was good in studies and made a lot of friends, was a stable extrovert. Dietary history revealed non-vegetarian preference, pulses and cereals. She had a special liking for fried dals like moongdaal and daaalmoth (a fried readymade preparation of yellow and black and green lentils, flakes, groundnut and spices). She used to munch on this item throughout the day. Fruit and salad intake was minimal and fish was consumed in the house once or twice a week.

Mother gave h/o similar smell in the father described as "rotten egg like" emanating from her husband and she gave horrid details of the difficult time she had with him after marriage due to this odor ("only I know how I have tolerated him. He being a male could get away with it but she is a girl, who will tolerate her").

There was no past h/o mood abnormality or genetic loading of mental illness or suicide in the family.

Examination revealed increased tendency to sweating. Mental state examination revealed features of depression of moderate intensity and embarrassment with social isolation and disturbed sleep off and on. …