A 71-year-old right-handed woman presented with a two-year course of reduction in strength. Her strength loss involved both hands with progressively worsening weakness in both thumbs and index fingers. Over time, she developed dyspnea, even without exertion. Nocturnal muscle spasms of all four extremities was also reported. She denied any sensory or vision problems. Over the last 8 months she’s lost 10 lbs, but denies difficulty in swallowing or hunger, but states that with the exception of liquids, virtually all solid food tastes disgusting to her. She’s able to drink water without a similar repulsive sense. Non-food odors are not bothersome and she does not report any smell rot. She states food taste and smells as it always tasted, but now finds them repugnant, particularly upon mastication.

There are myriad origins for cachexia at the end stage of neurological disease. This patient’s absence of dysgeusia with perceived perception of normal taste to food suggests a cortical origin for her cacogeusia. Such cortical function would correspond with hedonic changes in ALS and is consistent with evidence of cortical (cognitive) impairment in 28.5% ALS patients (Crockford, 2018). Modulation of hedonic mechanisms may have usefulness upon the associated cachexia. The absence of cacosmia with orthonasal olfaction but presence of cacogeusia with retronasal olfaction implies that the primary abnormality is not due to end organ dysfunction to the olfactory system. Study of interventions impacted is warranted.