Sixty seconds on . . . anosmia
BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m1202 (Published 24 March 2020) Cite this as: BMJ 2020;368:m1202Read our latest coverage of the coronavirus outbreak
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Anosmia: wake up and smell the symptom
News reports from around the world have been noting sudden onset anosmia or ‘smell and taste’ loss as indicators of coronavirus for weeks. ENT specialists and family doctors in the UK are recognising that smell and taste loss could be a marker in asymptomatic carriers of the virus. In France, people with loss of taste and smell are being told to isolate even without the presence of the persistent cough and high temperature. In the UK, Chief Scientific Adviser Sir Patrick Vallance admitted at his Monday 30th briefing that "Loss of taste and smell is something that can happen with other respiratory viruses as well. It does seem to be a feature of this from what people are reporting and it is obviously something that people should take into account as they think about their symptoms." We would argue that there is now enough evidence to take this symptom much more seriously.
Anecdote must be heeded when it provides clues for researchers to follow. There are numerous high-profile media accounts of famous people experiencing smell and taste loss. Gary Linekar’s 28 year old son ‘necks a bottle of vinegar’ to show how off how his senses have been effected (Alex Wood, Daily Star Online, March 31); Broadway star Aaron Tveit was largely asymptomatic other than smell and taste loss but tested positive for the virus in mid-March (Hollywood reporter, March 23). Then there was Utah Jazz star Rudy Gobert (Jack Rathborn, Independent, March 23); Health minister Nadine Dorries and Dancing on Ice star Matt Evers (Sabrina Barr, Independent, March 23). In early March, ENT surgeons in the UK had begun to notice an increase in people attending surgeries for smell and taste loss. As reported in the Daily Telegraph, Prof Claire Hopkins, president of the British Rhinological Society, said "I saw nine young people with loss of sense of smell who were otherwise fit and well this month. That's extremely unusual, I might usually see one a month," (March 30). They subsequently put out a statement on loss of smell and taste as a marker for Covid-19 for researchers [1] and patients [2].
Meanwhile hard data continue to emerge. Just this morning (01/04/20) newspapers are reporting pre-publication findings from the 1.5 million users of Kings Colleges the Covid-19 symptom tracker app that 59% of those with a positive test for the virus reported loss of smell (and impact on taste) [3]. A survey of appr 10,069 Iranian subjects shows a correlation of 0.87 (p<0.001) with smell and taste loss [4], and an Italian smaller study again reports similar findings. The latter suggests what seems to be the emerging hypotheses around COVID-19 related anosmia, that is the binding of COVID-19 to ACE2 receptors (which are plentiful in the naso-pharyngeal tract) that accounts for the uniqueness of this symptom, and that it is not just secondary to a mucosal build up that could occur in any flu-like virus [5].
A further stand of evidence comes from the recently established Global Consortium of Chemosensory Scientists (Twitter @GCChemosensoryR) [6], an international team of clinicians and sensory scientists, who are currently working to understand reports of COVID-19 chemosensory issues. They have established a private Facebook group [7] as a discussion forum for anyone concerned about the relationship between smell/taste and appetite loss and Covid-19. In less than 7 days, with very little publicity, 700 people had become members and were reporting loss of smell (or ‘taste’) and deep anxiety about the symptoms. Reading through their posts, it is clear that anosmia is affecting otherwise healthy (and young) people all over the world and that in the cases where they have been tested for the virus, all are positive. Alarmingly, many of these reports indicate that people have had diminished taste/smell for days or weeks and are finding their concerns are not being taken seriously, are confused at government inactions and very few have been given advice to self-isolate.
The ENT-UK position statement advising people to self-isolate based on anosmia released on 24th March has not yet changed the official position [8]. We acknowledge that the research cited here is just published or pre-publication, and that anecdote is a precarious basis for decision, but taken together with the worldwide reports of sudden onset anosmia from China, South Korea, Iran, Germany, Italy and now the UK, there does seem to be an emerging picture of smell loss as an important marker of COVID-19 and, crucially, one that often seems to occur in advance of other symptoms and may, in some, be the only symptom. Early identification of anosmia as a potential marker of infection could help both target testing and diminish the spread of COVID-19.
References
1 https://www.entuk.org/sites/default/files/files/Loss%20of%20sense%20of%2...
2 https://www.entuk.org/sites/default/files/files/Advice%20for%20patients%...
3 https://www.kcl.ac.uk/news/loss-of-smell-and-taste-a-key-symptom-for-cov...
4 https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa330/581...
5 https://www.medrxiv.org/content/10.1101/2020.03.23.20041889v1.full.pdf
6 https://twitter.com/GCChemosensoryR
7 https://www.facebook.com/groups/Covid19SmellTasteLossGCCR/
8 https://www.entuk.org/sites/default/files/files/Loss%20of%20sense%20of%2...
Competing interests: No competing interests
Dear Editor
This is a response to the idea that anosmia is a stigma of COVID-19.
No it is not.
Some years ago (long before COVID-19 is reported to have been identified anywhere in the world) I suffered a severe attack of naso-pharyngitis and sinusitis. And lost my sense of smell totally. Inevitably the sense of flavour suffered. Bare taste was unaffected.
Hearing too was diminished in one ear.
NHS was unable to help.
A private doctor in London prescribed FLUTICASONE PROPIONATE 400 microgram nasal drops (besides wax removal) to deal with the hearing problem.
An unexpected benefit after about one week, was a partial return of smell and flavour. This was preceded by liquified muco-purulent discharge from ONE nostril.
Clearly, the nerve fibres in the ethmoid had been blocked by the thick secretions.
A note of fore-warning. Please do not expect the 50 microgram preparation (ordinarily used for allergic rhinitis) to be equally effective. In my case it proved useless.
Conclusions:
1. Anosmia is the result of physical barrier - thick mucus - between the odoriferous particles and olfactory nerve end-plates. It is reversible when the barrier is removed.
2. The 50 microgram preparation is useless for this particular problem
3. Anosmia is not diagnostic of COVID-19.
Competing interests: No competing interests
Dear Editor,
The coronavirus disease 2019 (COVID-19) pandemic is currently challenging nearly 200 countries and territories around the world, with a case fatality rate of 4.5%. [1] Since 21 February 2020, Italy has become the worst-hit country, with the highest death toll of 6,820 (more than twice that in China) and 69,176 confirmed cases on 24 March 2020.
Prevalence of infection among healthcare providers reaches 9% in this country.
As a surgeon (37-year-old Caucasian male) practising in Veneto region, one of the worst-hit in Italy since the beginning of the outbreak, I was screened for COVID-19 on 19 March while being fully asymptomatic. Nasopharyngeal swab tested positive for multiplex real-time reverse transcription (RT-PCR). Myalgia and fever started overnight on 21 March reaching the highest body temperature of 38.6℃. Nausea and two episodes of vomiting occurred in the first morning. Dry cough was present solely on 22 March, associated with diarrhoea for two days. While feeling better in absence of fever and myalgia, I gradually became aware of being unable to smell (anosmia) or taste food on 22 March. However, as opposed to my inability to smell, the sense of taste was not entirely abolished but rather distorted (i.e. dysgeusia), with saltiness and sourness being the only unaltered taste modalities. No improvement in both symptoms has been noted as yet.
Previously described coronaviruses are thought to account for 10-15% cases of post-viral anosmia. [2] While sweet, bitter, and umami tastes are transduced by G-protein-coupled receptors, transient receptor potential ion channels are thought to mediate saltiness and sourness taste. It is therefore reasonable to assume that COVID-19 infection may selectively alter signal transduction pathways. Further research is needed to confirm this hypothesis.
REFERENCES
1. https://www.who.int/emergencies/diseases/novel-coronavirus-2019. Accessed March 25, 2020.
2. https://www.fifthsense.org.uk/covid-19-corona-virus-and-smell-loss-guida.... Accessed 24 March 2020.
Competing interests: No competing interests
Re: Sixty seconds on . . . anosmia
Dear Editor,
We now need an objective test for confirming anosmia and dysgeusia in patients with suspected COVID. Two days after my positive COVID swab, I noticed a complete lack of the sense of smell, and am here testing it with a freshly cut onion, which is a well-recognised potent stimulus. This test can be quickly validated, but I suspect will have a very high specificity. In patients who have lost their sense of smell therefore, this test can be used as a surrogate for COVID swabbing, until we have adequate tests available.
http://imperialendo.co.uk/Newskills/meeranONIONtest.mp4
Competing interests: No competing interests