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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
History.
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]
Discussion
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.
[ CLOSE WINDOW ]
References
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: http://en.wikipedia.org/wiki/Diacetyl Accessed December 16, 2010.
Medscape Infectious Diseases © 2010 WebMD, LLC
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
History.
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]
Discussion
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.
[ CLOSE WINDOW ]
References
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: http://en.wikipedia.org/wiki/Diacetyl Accessed December 16, 2010.
Medscape Infectious Diseases © 2010 WebMD, LLC
