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Mark Crislip, MD

Chief, Infectious Diseases, Legacy Health System, Portland, Oregon

From Medscape Infectious Diseases > Case Challenges -- Infectious Disease
When Is a Lung Abscess Like Popcorn?
Mark Crislip, MD
Posted: 12/29/2010
Clinical Presentation
The patient is a 17-year-old girl who had been sick for 1 week prior to admission to the hospital. She had constant right upper quadrant pain and pleuritic right-sided chest pain. She was seen as an outpatient and treated with Tylenol® with Codeine #3. The pain did not abate so she was again seen by her primary care provider who told her she had costochondritis, and she should take nonsteroidal anti-inflammatory drugs.

Three days later she observed that her skin was yellow, her urine was orange, and she had developed progressive shortness of breath with a productive cough. She was seen in the ER and admitted to the hospital.

She denied having fevers, chills, cough, or other complaints until the day of admission.

History and Physical Examination


The patient's past medical history was negative. Current social history:

Student: in suburban high school;
Pets: 4 birds, 2 dogs, cat;
Travel: to Eastern Europe 6 months ago; and
Habits: no bad habits; plays the saxophone.
Physical examination.

On physical examination, the following were noted:

General: ill-appearing and jaundiced; splinting when talking;
Vital signs: temperature 39 degrees C; respirations 24 breaths per minute, pulse 110 beats per minute;
HEENT: yellow sclera;
Lungs: decreased breath sounds on right side, with "e" to "a" changes;
Heart: grade 2/6 murmur; and
Abdomen: slight right upper quadrant tenderness to palpation.
Laboratory value and imaging results.

WBC: 25,000 with 36% bands;
Bilirubin 9.2 mg/dL;
ALP 114 U/L; AST 199 U/L; ALT 103 U/L;
CT abdomen: mild hepatosplenomegaly;
Ultrasound: normal gallbladder;
CXR: lemon-sized thick-walled cavity with air-fluid level and large effusion.
What is the diagnosis?
( )Tuberculosis
( )Psittacosis
( )Leptospirosis
(X)Mixed bacterial lung absess
( )Legionella
[Save and Proceed]


Differential diagnosis.
Tuberculosis (TB) is a reasonable guess, given this clinical presentation, except for the relatively acute onset of illness and the hyperbilirubinemia. This patient's TB exposure history is minimal, except for her recent trip to Eastern Europe.

Psittacosis commonly causes pneumonia with hepatosplenomegaly. However, lung abscess and hyperbilirubinemia are extraordinarily rare with this infection.

Leptospirosis causes hyperbilirubinemia out of proportion to transaminase levels, but is usually associated with acute renal failure. Leptospirosis does not cause a lung abscess, and, while the dogs could be a source of infection, leptospirosis is typically acquired from fresh water exposure.

Legionella does not cause early lung abscess, although non-pneumophila Legionella can cause lung abscess in the immuno-incompetent. Legionella is not associated with hyperbilirubinemia.

Cultures of the patient's lung abscess were performed and the pleural fluid grew Streptococcus anginosus and Eikenella corrodens, both mouth organisms.

But why a mixed bacterial infection? Usually mixed lung abscesses are seen in people with poor dentition or people with decreased levels of consciousness, which leads to aspiration of saliva.[1]

The Sax Connection

I postulate that this patient's pneumonia was caused by her saxophone playing. While playing, she uses circular breathing, which allows the epiglottis to remain open.

"Circular breathing is a technique used by players of some wind instruments to produce a continuous tone without interruption."[2] This is accomplished by breathing in through the nose while simultaneously blowing out through the mouth using air stored in the cheeks."

The circular breathing could allow aspiration of oral flora. Pulmonary trauma has been described from prolonged saxophone playing, and this could serve as fertile soil for bacterial growth.[3] Saxophones fill up with saliva, which can be emptied requiring a spit valve for occasional emptying, and tilting the saxophone up during the "funky refrain" could facilitate backwash of the stored salvia into the lungs, even though the patient cannot remember a specific aspiration event. Molds have been isolated from saxophones; no one has yet done bacterial cultures.

Finally, saxophone players have a shortened life expectancy compared with other musicians.[4] The mode of death, in a nonscientific Google search, is not heroin use, but pulmonary disease, often pneumonia.

Figure. Kaplan-Meier survival curves from saxophonists and other instrumentalists.
From Kinra S, et al. BMJ. 1999;319:1612-1613.[4]

So this was a case of bacterial pneumonia from oral sax. (My emphasis: Jules)

The patient's hyperbilirubinemia was believed to be a consequence of bacterial infection and sepsis and resolved with antibiotics. Increased bilirubin is more common in bacterial infections in children; about 0.6% of adults with sepsis will have an increased bilirubin. Bilirubin can occur in 6%-46% of lobar pneumonias. Her bilirubin was at the upper limit of normal for what is described in the literature, where levels from 5 mg/dL to 10 mg/dL are reported. The mechanism is multifactorial.[5]

S. anginosus, one of the S. milleri group, is often found in lung, liver and brain abscesses. The curious thing about S. anginosus is that it smells like buttered popcorn or caramel. Why? It makes diacetyl. Lots of diacetyl.

"The caramel odor associated with the Streptococcus milleri group was shown to be attributable to the formation of the metabolite diacetyl. Levels of diacetyl in the 22- to 200-mg/L range were produced by 68 strains of the S. milleri group."[6]

Small amounts of diacetyl are found in beer and wine from the yeast fermentation and diacetyl gives beer and wine slipperiness. Or so says Wikipedia, which also says, "Concentrations from 0.005 mg/L to 1.7 mg/L were measured in chardonnay wines, and the amount needed for the flavor to be noticed is at least 0.2 mg/L."[7]

So the bacteria make 10-1000 times the amount of diacetyl found in wine. Why S. anginosus makes so much diacetyl remains unexplained.

So next time you have that microwave popcorn and a bottle of chardonnay, remember that the buttery richness is also is the odor of streptococcal abscesses.


1. Mager DL, Ximenez-Fyvie LA, Haffajee AD, Socransky SS. Distribution of selected bacterial species on intraoral surfaces. J Periodontol. 2003;30:644-654.
2. Weikert M, Schlomicher T. Laryngeal movements in saxophone playing: video-endoscopic investigations with saxophone players. A pilot study. J Voice. 1999;13:265-273.
3. Ko YC, Dai MP, Ou CC. Playing saxophone induced diffuse alveolar hemorrhage: a case report. Ir J Med Sci. 2010;179:137-139.
4. Kinra S, Okasha M. Unsafe sax: cohort study of the impact of too much sax on the mortality of famous jazz musicians. BMJ. 1999;319:1612â€"1613
5. Chand N, Sanyal AJ. Sepsis-induced cholestasis. Hepatology. 2007;45:230-241.
6. Chew TA, Smith JMB. Detection of diacetyl (caramel odor) in presumptive identification of the "Streptococcus milleri" group. J Clin Microbiol. 1992;30: 3028â€"3029.
7. Wikipedia. Diacetyl. Available at: Accessed December 16, 2010.
Medscape Infectious Diseases © 2010 WebMD, LLC

· Super Moderator
26,697 Posts
GAH!!!! People are STILL quoting from Kinra S et. al. article in BMJ. IT WAS A JOKE!!!!!

"To the Editor -- please read Dr. Kinra's letter to me, and my reply below.

Dr Kinra's letter to me:

Thank you for your email Dr Friedmann
The main aim of the study was to quantify the life expectancy of this generation of musicians.
We assumed that everybody would obviously realise that the cause was life style (and hence the pictures of two relevant saxophonists with their causes of death in the caption); the hypothesis of circular breathing was more 'tongue in cheek' which is reasonable in Christmas BMJ edition.
Kind regards

My reply:

Dr. Kinra:

Thank you for your reply. I reread the paper -- you provide little clue that the 'circular breathing' hypothesis is in jest. This article may represent very subtle British humor, but unfortunately, many people in the medical community and the public did not "get the joke." For example, the article was mentioned in the Washington Post and filtered down to the general public. Debb Starr wrote to tell me that the check out clerk at the grocery store asked her about the article because he knew Debb played sax -- he had almost decided to tell his son not to play sax because it's "hazardous to one's health", and was greatly relieved when Debb suggested it might be a spoof.

The Christmas issue is not the April Fool's issue. The article was written as if the findings and conclusions were legitimate, but "cute", in the same way as a feature story. If this were a general interest magazine, then fine, but in BMJ it is quite insidious because doctors and patients expect peer-reviewed science from medical journals. Am I to assume that your other two papers in BMJ were also jokes? Had I been an author of one of the other serious research papers in that issue, from which your spoof was not differentiated, I would be quite aggrieved. Partly at you, but certainly at the Editor. This report should have been a letter to the editor, not a scientific article. As an article it is misleading and, as we have seen, it has the potential to be taken seriously as valid peer-reviewed research. As such it also has the potential to taint all medical research as similarly bogus.

Finally, with all due respect, I think you are backpedaling on the 'circular breathing' hypothesis after heavy, and deserved, criticism. Lifestyle issues are barely mentioned in the article, and in neither your reply to me nor in the paper do you give a rationale as to why saxophonists' lifestyles might differ from other jazz musicians. That said, I believe that increased mortality in saxophonists of that generation may be the result of the incredible influence of Bird -- many horn players believed you had to use heroin to play like him and got hooked. Bud Powell's substance abuse, for example, did not have a similar influence on pianists. Another possibility is the oral nature of horn playing being associated with more cigarette and alcohol consumption. Neither of these mechanisms directly implicates the saxophone with higher mortality as does your article. On behalf of horn players everywhere, I respectfully urge you to submit a retraction, or at least a correction, to BMJ.

Peter D. Friedmann,MD,MPH
593 Eddy St. Providence, RI 02903
Submit rapid response
Published 15 March 2000"

· Super Moderator
26,697 Posts
Yes it is ridiculous to quote Kinra to support this article. Agreed. But the article isn't really about the Kinra study albeit disappointing it was dragged into the discussion.
If you use the Kinra study as a source, it's not exactly good science. Circular breathing does NOT involve the epiglottis. The entire 'postulation' of a sax 'cause' is absurd. You cannot determine cause from a positive correlation. You could aspirate bacteria from any number of sources.

No wonder MDs are notorious in academic circles for being poor researchers while being great physicians.

This is the sort of thing that causes parents to freak out, and not allow their children to play wind instruments.

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I had a patient like this (except mine survived). Similar story, though...nonspecific reproducible pain in one part of the chest. History and physical otherwise negative/normal. These kind of patients can be tough to diagnose. Very few clues early on.

· Super Moderator
26,697 Posts
I did not see where the patient died.

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266 Posts
I'm sorry but i don't think Dr. House is a member of this forum:mrgreen:
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