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Cite this article : Deborah Wardly. Multiple Chemical Sensitivity as A Variant of Idiopathic Intracranial Hypertension: A Case Report.
J J Neur Neurosci 2018; 5(2): 039.
Case Report
Multiple Chemical Sensitivity as A Variant of Idiopathic Intracranial Hypertension:
A Case Report
Deborah Wardly*
Debron Court, Pollock Pines, CA
*Corresponding author: Dr. Deborah Wardly, Debron Court, Pollock Pines, CA. Tel: 916-712-0704; Fax 505-212-1712; Email:
deborahwardly@yahoo.com
Received Date: 12-03-2018
Accepted Date: 12-10-2018
Published Date: xx-xx-xxxx
Copyright: © 2018 Deborah Wardly
Abstract
Introduction: There is currently no recognized association between intracranial hypertension and multiple
Case Report: This case report details the complex case of a woman who has multiple chemical sensitivity and
Conclusions: This paper discusses the similarity between the neurological symptoms and the illness model
sensitivity is actually a variant of idiopathic intracranial hypertension, and argues for further investigation of
exposure mediates the production of increased intracranial pressure by way of an effect on brain edema as
consumer products have been demonstrated to contain multiple volatile organic compounds that are
Keywords: Idiopathic Intracranial Hypertension; Multiple Chemical Sensitivity; Environmental Intolerance;
Jacobs Journal of Neurology and Neuroscience
Jacobs Publishers
Cite this article : Deborah Wardly. Multiple Chemical Sensitivity as A Variant of Idiopathic Intracranial Hypertension: A Case Report.
J J Neur Neurosci 2018; 5(2): 039.
2
Introduction
This paper will discuss a case report of a complex
patient who has both Multiple Chemical Sensitivity (MCS)
points out the similarities between these conditions and
provides a link between them which suggests that MCS may
Idiopathic Intracranial Hypertension
Idiopathic intracranial hypertension has also
been called pseudotumor cerebri and benign intracranial
pressure; 2) no localizing signs except abducens nerve
(c) Aggravated by coughing or straining
criteria:
(a) Alert patient with neurological examination that either
is normal or
demonstrates any of the following abnormalities:
(ii) Enlarged blind spot
(iv) Sixth nerve palsy
in the recumbent position or by epidural or intraventricular
pressure monitoring
Table 1:
Abbreviations
AHI Apnea-Hypopnea Index
CC-MMA
Counterclockwise Maxil-
lo-mandibular Advance-
ment
MCS Multiple Chemical Sensitivity
MRI Magnetic Resonance Imaging
MRV Magnetic Resonance Venogram
-
OSA Obstructive Sleep Apnea
CT Computed Tomography REM Rapid Eye Movement
fMRI -
nance Imaging -
ed Tomography
Glutathione S Transferase
Glutathione S Transferase
TSS Transverse Sinus Stenosis
VOC Volatile Organic Compound
IIH Idiopathic Intracranial Hy-
pertension TILT Toxicant-Induced Loss of Toler-
ance
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Cite this article : Deborah Wardly. Multiple Chemical Sensitivity as A Variant of Idiopathic Intracranial Hypertension: A Case Report.
J J Neur Neurosci 2018; 5(2): 039.
3
and cellularity
(d) Intracranial diseases (including venous sinus
thrombosis) ruled out by appropriate investigations
hypertension
(3) Headache develops in close temporal relation to
increased intracranial pressure
pressures much lower than previously recognized, as will
study looking at pediatric patients who had been diagnosed
and headache who had obvious improvement upon draining
suggest that there should be discussion of replacing the
2
Several pathophysiological mechanisms that may lead
cerebral venous pressure contribute to the elevation of
the absorptive mechanism of the arachnoid granulations or
recent discoveries about the glymphatic system may shed
to the venous blood of the dural sinuses may trigger the
are regional cerebral hypoperfusion abnormalities seen on
obese women with IIH, they manifested both increased
studies that have demonstrated the presence of increased
extra- and intracellular water content in the brains of
patients with IIH, and how this indicates an increased
suggesting a congestion of the glymphatic system which
pathway (either via intrinsic or extrinsic venous sinus
stenoses), then a secondary congestion of the glymphatic
One of the cardinal radiological signs of IIH is the excess of
not only along the optic nerve, but also along the olfactory,
facial, trigeminal, acoustic, oculomotor and abducens
patients with IIH, and how this may be a result of variations
Jacobs Publishers
Cite this article : Deborah Wardly. Multiple Chemical Sensitivity as A Variant of Idiopathic Intracranial Hypertension: A Case Report.
J J Neur Neurosci 2018; 5(2): 039.
4
primary problem with the aquaporin channel may be at the
root of the
The headache in IIH can mimic migraine or tension-
type headache patterns and IIH can exist in the absence of
papilledema, therefore proper diagnosis can be hindered
in obese women, however it can occur in males and in
fatigue, dizziness, impaired memory and concentration,
radicular pain, transient visual obscurations, photophobia,
phonophobia, pulsatile tinnitus, nausea, diplopia, and
There are many treatments for IIH but only rare
sinus stenosis (TSS) has been seen in a large majority
of patients however it is not known if the intracranial
pressure itself can compress the venous sinus, leading to
Intracranial hypertension can be caused by secondary
disturbances, obstructive sleep apnea, and cerebral venous
abnormalities, and at times the disease can be cured by
hypertension which is caused by certain medications can be
obstructive sleep apnea (OSA) can cause papilledema, OSA
is associated with IIH, and it is also known that apneas can
IIH has been demonstrated to be caused in some people by
internal jugular venous compression in part by an elongated
Multiple Chemical Sensitivity
Multiple chemical sensitivity (MCS) is a chronic
after exposure to low levels of environmental chemicals,
which they inhaled, absorbed or ingested a toxic level of
are volatile organic solvents and pesticides, although
a hypersensitivity to low levels of multiple different
these chemicals than normal people, and generally they
achieve a relatively normal baseline as long as they avoid
anxiety, sleepiness, irritability, panic disorder, migraine
has recently been demonstrated that patients with MCS
for this illness: toxicant-induced loss of tolerance (TILT),
which emphasizes that there is an initiating event with
on TILT detail further symptoms these patients describe,
ringing in ears, headache, feeling groggy, weakness, double
Jacobs Publishers
Cite this article : Deborah Wardly. Multiple Chemical Sensitivity as A Variant of Idiopathic Intracranial Hypertension: A Case Report.
J J Neur Neurosci 2018; 5(2): 039.
5
The response to low levels of environmental
chemicals has led to the development of a theory of neural
is the process by which an organism learns to augment the
response to threatening stimuli in order to protect against
indicating that the effects of this chemical exposure are
for this idea that the symptoms of MCS are mediated by
an anti-epileptic medication which reduces the release of
presynaptic neurotransmitter including glutamate, was
shown to improve the recurrent symptoms of a 23-year-old
The search for biomarkers in MCS has yielded
correlations between alterations in catalase, glutathione-
spectroscopy imaging demonstrated an increase in cerebral
positron emission tomography, abnormal activation of the
amygdala, piriform and anterior cingulate cortex during
imaging studies investigating differences in brain glucose
consumption have also demonstrated alterations from the
norm in MCS patients, implying that brain metabolism in
MCS subjects during olfactory stimulation is different from
Many researchers and clinicians have concluded
into the category of somatic symptoms disorder, even
now when there is a great deal of evidence that MCS is a
patients have problems with, this does not support a
quantity and funding of quality research into the biology
exposure to triggering substance leads to illness, removal of
substance leads to improvement or resolution of symptoms,
to the medication induced intracranial hypertension
described in MCS are nearly identical to those described in
There does not appear to have ever been an
case report in the literature showing an association of MCS
in a woman who had intracranial hypertension, presumably
meningioma, however her MCS symptoms did not resolve
Jacobs Publishers
Cite this article : Deborah Wardly. Multiple Chemical Sensitivity as A Variant of Idiopathic Intracranial Hypertension: A Case Report.
J J Neur Neurosci 2018; 5(2): 039.
6
demonstrates that at least in this patient, her MCS symptoms
are identical to her IIH symptoms, chemical exposure
triggers her IIH symptoms and this is shown to correlate
IIH was put into remission with jaw surgery, and while her
odor hypersensitivity is unchanged afterwards, the degree
of her neurological response to chemical exposure, while
the suggestion that the neurological symptoms in MCS
are a result of chemical exposure leading to an increase
explores this possibility and hypothesizes that the increase
development of cerebral edema initiated by the chemical
Case Report
The woman in this case report developed Graves
began having symptoms that in retrospect may have been
the onset of idiopathic intracranial hypertension (daily
after Graves diagnosis, she noted the onset of headache and
She developed proptosis as well as vertical phoria and had
a total thyroidectomy, after which point all of her symptoms
improved for quite some time and the eye disease became
was bothering her a lot, and that it was triggering her
told that no one else was smelling what she was, and that
trouble whenever someone used the Lysol spray in the
Table 2:
MCS IIH
Memory problems Memory problems
Concentration problems Concentration problems
Lightheadedness
Headaches Headaches
Tinnitus
Joint pains Joint pains
Triggered by toxin exposure Triggered by drug exposure
Helped by toxin removal Helped by drug removal
Osmophobia
Osmophobia
Jacobs Publishers
Cite this article : Deborah Wardly. Multiple Chemical Sensitivity as A Variant of Idiopathic Intracranial Hypertension: A Case Report.
J J Neur Neurosci 2018; 5(2): 039.
7
mask in her work bag so she could use it if needed to protect
was having to use it so much that it was interfering with
(however not notable as unusual by others present)
her having to claim disability because of her inability to
tolerate indoor work environments due to the chemical
exposures which were causing both respiratory and
taper course of steroids, and while on this her asthma was
after stopping the steroids, and immediately after dieting
beyond fatigue, but a feeling like one is deep underwater,
function with this extreme alteration in her sensorium,
which would come and go and appear to be aggravated by
Chemical exposures could cause episodes of brain fog and
was initially diagnosed with multiple chemical sensitivity
(MCS), given her history of poor odor tolerance of chemical
carries several genetic polymorphisms associated with
which cause her trouble are hydrocarbons, or VOCs (volatile
the GSTs are highly expressed in the olfactory epithelium,
this patient who harbors two genetic anomalies involving
have severe symptoms which were ultimately diagnosed
Regarding her headache history, these were
accompanied by brain fog and occasionally nausea, but
intermittent headaches going back to childhood, prior to the
pounding, were moderate and occasionally severe, and
could be triggered by altitude changes, food sensitivities
did have odor hypersensitivity, her symptoms could occur
from chemical exposures in the absence of odor perception,
and neurological changes from chemical exposure below
airway symptoms that at times led her to gasp for air and
become lightheaded, triggered by eating, only to resolve
completely after a midline glossectomy, however her AHI
retaining device, when it stayed on without fail, worked
well to prevent the brain fog and headaches, leading to the
but not completely, however it was more reliable than the
Jacobs Publishers
Cite this article : Deborah Wardly. Multiple Chemical Sensitivity as A Variant of Idiopathic Intracranial Hypertension: A Case Report.
J J Neur Neurosci 2018; 5(2): 039.
8
using it, and while using it she had a near syncopal episode
episode was triggered by a Valsalva maneuver, and in the
positive because her brain fog symptom improved after
was diagnosed with idiopathic intracranial hypertension
which explained most of her neurological symptoms which
included the brain fog, headache, tinnitus, pulsatile tinnitus,
Crying would trigger an immediate ice-pick type headache
with her initial diagnosis of MCS, chemical odor was a
could ruin her day, render her unsafe to drive, or put her
to the scent, yet if the exposure persisted despite her no
pressure, she experienced the expiratory pressure as a
Valsalva and after one night she developed an episode of
that allowed her to increase the inspiratory pressure
treatments despite having only mild OSA that was triggering
her IIH, and that she had failed medical management of
the IIH, as she was unable to tolerate acetazolamide or
worked to abort the symptoms triggered by OSA, however
clockwise maxillomandibular advancement (CC-MMA)
after the procedure, she began to feel much better and was
able to exercise again after years of feeling lightheaded and
sleep apnea other than a nasal decongestant at bedtime,
and while she continued to have symptoms of sleep apnea
such as waking with a sore throat, her IIH symptoms were
exposure, her headaches were rare and the brain fog was
milder overall and could go away on its own within an hour
fog could become deep enough to cause her to feel she was
unsafe to drive, if she allowed a longer exposure, however
these events would still usually clear rapidly once removed
starting to cry could precipitate an ice-pick type headache
to the CC-MMA, she could feel dizzy just from shouting, while
post surgery she could speak, shout, laugh and cry with no
she could now speak animatedly and rapidly, whereas prior
to the CC-MMA she was soft spoken and moved slowly, with
repeat sleep study at Stanford which showed an AHI of
Jacobs Publishers
Cite this article : Deborah Wardly. Multiple Chemical Sensitivity as A Variant of Idiopathic Intracranial Hypertension: A Case Report.
J J Neur Neurosci 2018; 5(2): 039.
9
to a hanging car air deodorizer, and a common room air
discussion which follows, it should be noted that the
woman in this case report has a son with autism, who is
also chemically sensitive, and who has also been diagnosed
Discussion
This is the case report of a very complex patient who
carries the diagnoses of obstructive sleep apnea, idiopathic
In this patient, these three conditions appear to interact so
intimately that at times it is as if they are one condition with
of IIH was atypical, with her opening pressures being in
Valsalva triggers for symptoms did suggest that intracranial
without papilledema, which can be associated with a
Even if her IIH diagnosis prior to CC-MMA might be arguable,
her clinical improvement afterwards coincident with a
case report, the CC-MMA appeared to eliminate her IIH, as
2
that this cure was effected by the mandibular advancement,
independent of the effect on sleep apnea, given that the AHI
it was proposed that the mandibular advancement led to
the fact that prior to CC-MMA the tongue retaining device
helped more than any other sleep apnea treatment, and by
the fact that total thyroidectomy led to initial remission of
IIH symptoms (these may have decompressed the internal
The discussion here will focus on this patient’s
exposure is still in what is considered to be the normal range
with the increase, and there is no valid reason other than the
of the manometer, and the hole in the dura from the spinal
needle even though it was left in place can allow leakage of
suggest that this patient’s MCS has been a manifestation of
the CC-MMA in this patient corrected her jugular venous
implied that there may be a system wide problem with the
endothelial barrier in IIH that predisposes to edema not just
that this patient may experience brain edema triggered
the brain fog symptom is caused in large part by this brain
Jacobs Publishers
Cite this article : Deborah Wardly. Multiple Chemical Sensitivity as A Variant of Idiopathic Intracranial Hypertension: A Case Report.
J J Neur Neurosci 2018; 5(2): 039.
10
basic systemic problem with the endothelial barrier, this
may explain the gastrointestinal and pulmonary symptoms
may be best directed at this interface, and there is evidence
matters, it has been shown that intermittent hypoxia can
Alternatively, it has been recently demonstrated
that patients with MCS can experience a regional increase
MCS has been shown in multiple studies using near-infrared
baseline hypoperfusion, it is likely that our understanding
The functional MRI results obtained on this patient
indicate that very low levels of chemical are capable of
This is clearly a pure neurological reaction to the chemical
exposure itself, and not a psychological response to the
odor perception, because the patient did not perceive the
that this brain activation may be mediated by glutamate,
has demonstrated that the VOC formaldehyde likely exerts
biologically plausible connection between (typically VOC)
chemical exposure and the production of brain edema
which may then cause neurological symptoms in MCS and
may raise intracranial pressure to abnormal levels such
increases initially due to edema or to increased cerebral
It is also known that obstructive sleep apnea can
OSA causing brain edema could explain the fact that
prednisone was able to abort this patient’s symptoms
hypothesizes that somatic syndromes (like MCS) are linked
to sleep disordered breathing via neural sensitization to
that the chemical exposure triggers the neural sensitization,
however it may be that OSA plays into the development of
been found to have increased nasal resistance compared
to have higher blood pressures upon waking, compared
to normals, and also show decreased total sleep times,
These are all signs seen in patients with sleep disordered
showed that patients who were environmentally intolerant
to chemicals showed higher levels of obstructive breathing
A recent hypothesis involving atrial natriuretic peptide
(shown to be elevated in OSA) also suggests that neural
sensitization may be involved in the symptoms of upper
These correlations between MCS and OSA, and those
previously mentioned between IIH and OSA, combined
with the data here suggesting that MCS may be a form of
IIH, intersect with the clinical presentation of the patient
in this case study to suggest that these three conditions are
interdependent on one another in the patient to produce
It would be important for this case study to be
followed by further investigation into whether a group
can be triggered to increase above baseline by exposure to
group would be important for determining if people who do
not carry a diagnosis of MCS also show an increase of their
to choose substances for study which are xenobiotics and
studies evaluating odor response in MCS patients employ
substances is evidence of an assumption about this illness
which may be mistaken: that the odor sensitivity in MCS is
primary to the illness, rather than being simply downstream
MCS, there seems to be a bias towards the idea that these
discussion here is attempting to demonstrate that these
question, regardless of their odor, which occurs due to
if MCS is determined to be due to a form of intracranial
hypertension which is triggered by an idiosyncratic
reaction to chemical exposure and exacerbated acutely by
chemical exposure, then it may be an illness characterized
by acute or chronic neurological injury worsened by acute
toxic reactions, rather than one produced by a total toxic
these patients to move them into the sphere of neurologists
who can address what may be the primary physiological
patients had improvement in their symptoms with removal
pressure utilized patients who were not completely normal
neurologically, and they suggest that we may not know what
It is also important to note that the lack of recognition up
to this point that intracranial pressure may be abnormal
about papilledema being required for the diagnosis of
is fact regarding the range and frequency of pathology in
It would be important to look at this problem from
be investigated for signs of previously unrecognized
odor hypersensitivity and chemical sensitivity exist in
because it is not generally recognized that these are regular
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Cite this article : Deborah Wardly. Multiple Chemical Sensitivity as A Variant of Idiopathic Intracranial Hypertension: A Case Report.
J J Neur Neurosci 2018; 5(2): 039.
sensitivity and odor hypersensitivity are frequently
mistaken for somatoform disorder manifestations; it would
be important to document that these are actually common
discrimination, such that proving that they have a legitimate
disease will go far in protecting the basic human rights of
It might also be productive to investigate the
frequency in IIH of the gene polymorphisms found to be
surgery of this patient’s chemically triggered neurological
symptoms suggests that it takes more than just a gene
a case of needing multiple strikes for the full syndrome
should be evaluated in multiple steps, including not only
products have revealed the presence of multiple VOCs
deletion and polymorphism would indicate that she would
conjugation, and this may be the reason why these type
contribute to neural sensitization and also to IIH in this
account for why some patients develop IIH from retinoids
being considered a rare disease, there are many who
on the prevalence of fragrance sensitivity in the American
study calls into question the etiology of these headaches,
and demands further study into the full spectrum of illness
caused by fragrances which have become so ubiquitous in
A Piece of the Autism Puzzle?
A very recent study of women with MCS by Heilbrun
chemically sensitive mothers reported that their children
had a greater sensitivity to noxious odors more often than
as well as one study suggesting that exposure to volatile
vitro experiments demonstrating increased mutagenicity
and cytotoxicity caused by common perfumes, has led to
the proposal of an hypothesis that these fragrances are
data, it is notable that the patient in the present case study
More notable is the fact that this child also has intracranial
to account for the autism and chemical sensitivity in children
here, one must consider that the genetic component may
to discovering the etiology of autism is found in some recent
although studies
showing the range of intracranial pressure in autism have
Jacobs Publishers 12
Cite this article : Deborah Wardly. Multiple Chemical Sensitivity as A Variant of Idiopathic Intracranial Hypertension: A Case Report.
J J Neur Neurosci 2018; 5(2): 039.
have also been seen in children with pseudotumor cerebri,
where the pressure in intracranial hypertension begins,
it is commonly accepted that a transient disturbance of
They raise the idea that without proper function of the
glymphatic system to clear metabolic byproducts from the
brain, there may be a pathological effect on normal brain
hypertension exists during early neurodevelopment, the
clinical syndrome will undoubtedly present differently than
the idea that intracranial pressure may be elevated in these
autistic children, but hopefully future studies will address
rather than an isolated build up of toxins due to glymphatic
anterior fontanelle provides increased cranial compliance
compliance is lost and pressure will rise if there is a problem
Given the recent information about the need for
2O for
diagnosis of pediatric IIH, it should be anticipated that a
Higgins study results imply that any research done should
MCS is IIH, if autism is determined to be related to elevated
intracranial pressure then there is suggestion for further
research as to the cause of these intracranial pressure
play a role, however the knowledge that MCS is triggered
by pesticides implies that research on how pesticides affect
the blood brain barrier and molecules involved in water
the fact that normal sleep is necessary to allow clearing of
toxic substances from the brain, and suggest that disrupted
sleep may have contributed to the impaired circulation of
autism have sleep problems, more so than neurotypical
children, and that autistic children with sleep problems
show daytime behavioral improvement with interventions
autism had evidence of a greater prevalence of OSA based
on a questionnaire of OSA symptoms, than did neurotypical
in autism based on sleep study evidence has yet to be
disrupted sleep but also contributed to the symptoms of
in the present case study, that the neuropathological effects
clinical manifestations will be different when this occurs
A further topic for discussion is the frequency of
As previously discussed, these are known to occur in MCS
different types of sensory disorders in these conditions
is uncommonly measured, and not well recognized in
Jacobs Publishers 13
Cite this article : Deborah Wardly. Multiple Chemical Sensitivity as A Variant of Idiopathic Intracranial Hypertension: A Case Report.
J J Neur Neurosci 2018; 5(2): 039.
frequency of the different types of sensory problems in
the cranial nerves which sub-serve our senses of sight,
that IIH can result in blindness, hearing loss, and olfactory
cardinal radiological signs of IIH is the swelling of the optic
nerve sheaths from this lymphatic congestion, but there
sensory loss, lesser congestion of the cranial nerves might
result in a hypersensitivity or distortion of some of the
senses, producing hyperacusis, osmophobia, and vertigo?
an investigation into the presence of a disorder of elevated
IIH, and autism suggests that these conditions may be more
Summary
This case report discusses a very complex patient
with obstructive sleep apnea, idiopathic intracranial
was eliminated by jaw surgery with CC-MMA, and her
exposure, suggesting that her IIH and her MCS are one and
exposure may be causing brain edema, via glutamate neuro-
is the suggestion that MCS is a variant of IIH, or that MCS is
a feature of IIH, and further study is required to elucidate
considered a secondarily caused intracranial hypertension
summarized research, that MCS is a neurobiological illness,
such that all claims of this condition being evidence of
a lumbar puncture in addition to an extensive medical work
up should ensue upon presentation of chemical sensitivity
symptoms which resemble IIH, and psychopathology
research showing correlations between MCS and autism
the importance of the lymphatic drainage pathway in IIH
suggests a new avenue into investigation of the etiology of
Acknowledgments
A case report entitled: “Idiopathic intracranial hypertension
eliminated by counter-clockwise maxillomandibular
published in Cranio and contains some word for word
This
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idiopathic intracranial hypertension in men: a case-
Jacobs Publishers 14
Cite this article : Deborah Wardly. Multiple Chemical Sensitivity as A Variant of Idiopathic Intracranial Hypertension: A Case Report.
J J Neur Neurosci 2018; 5(2): 039.
chronic fatigue syndrome and idiopathic
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improves symptoms of multiple chemical
polymorphisms in patients with multiple chemical
Jacobs Publishers 15
Cite this article : Deborah Wardly. Multiple Chemical Sensitivity as A Variant of Idiopathic Intracranial Hypertension: A Case Report.
J J Neur Neurosci 2018; 5(2): 039.
of odor thresholds and responses in cerebral
stimulation in patients with multiple chemical
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disordered breathing, behavior, and cognition
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Cite this article : Deborah Wardly. Multiple Chemical Sensitivity as A Variant of Idiopathic Intracranial Hypertension: A Case Report.
J J Neur Neurosci 2018; 5(2): 039.
natriuresis to an understanding of the clinical
chemical and drug intolerances: potential risk
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abnormalities in autism detected through
in infancy: clinical presentation and long-term
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presentation of chronic intracranial hypertension
olfactory impairment in idiopathic intracranial
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Cite this article : Deborah Wardly. Multiple Chemical Sensitivity as A Variant of Idiopathic Intracranial Hypertension: A Case Report.
J J Neur Neurosci 2018; 5(2): 039.
