Jerry was in fine form as he stood at center stage, his hand resting on the microphone stand, waiting for the laughter to subside. He had invited me to watch him perform stand-up at this West Los Angeles comedy club, and he didn’t disappoint. But his wife, Sandy, wasn’t laughing. She leaned across the small cabaret table we were sharing and said, “I need to talk to you about Jerry.” They had both been patients of mine for many years. Both were late middle-aged, and neither had ever had a serious medical problem. I looked at her quizzically and she said, “His breath.”
I leaned closer and asked, “What about his breath?”
“It’s different. Not bad, but it’s changed. Something’s not right.”
“Maybe three months.”
I asked if anyone else had mentioned anything, and she shook her head.
“How does he feel?”
“He says he feels fine. But something is wrong. I’m his wife and I can tell. Something has changed.”
I looked up at Jerry. He was pulling faces now, mimicking his elderly father as part of his routine. The audience was loving it.
“Have him come see me in the office,” I told Sandy.
“Honest to God, doc, I’m fine,” Jerry insisted a week later. “If you ask me, I think it’s my wife’s sniffer that needs a checkup.” Jerry did indeed look well, and when I put my face close to his and asked him to exhale through an open mouth, I could detect no unusual or unpleasant odor. Likewise, when I had him breathe out through his nose, nothing struck me as especially noxious.
He told me there had been no recent dental problems, sores in his mouth, or other symptoms. He didn’t wear dentures and hadn’t begun using any new medications or supplements. The examination of his nose, mouth, tongue, throat, and gums was unremarkable to my internist’s eye. I took one more sniff. Nothing. Frankly, I wasn’t sure that anything was wrong, but I told him to go see his dentist.
“I was just there three months ago,” he protested. “Everything was OK.”
I nodded and said, “See him again anyway.” Halitosis, defined as a foul or fetid odor carried on the breath, originates in the oral cavity or sinuses 80 to 90 percent of the time. The literature reports that it occurs in about 15 to 30 percent of the population. Since it is often difficult to notice one’s own odor, millions of people walk around with bad breath and don’t know it.
The malodor of halitosis usually results from the bacterial breakdown of amino acids in food debris, saliva, blood, and postnasal drip in the oral cavity. The residue of everything from caviar to cannoli provides the raw material for the volatile sulfur compounds primarily responsible for the offensive smell. Concentrations of the culpable microbes are particularly heavy in the spaces between the teeth and gums and on the back of the tongue.
The nasal passages and sinuses are the second-most common source of bad breath. Less common causes in the mouth are diseases such as gingivitis. Although an assortment of illnesses—such as advanced kidney disease and liver failure—can cause unpleasant odors on the breath, it is rare for any of them to produce halitosis without any other signs or symptoms.
Two weeks later I got a call from Sandy. “So, what did the dentist find in your husband’s mouth?” I asked.
“Nothing,” she told me. “The dentist didn’t even think his breath was bad. He just told him to floss regularly and gave him a toothbrush. But I know something’s wrong. Can’t you just give him some antibiotics?” She was obviously frustrated.
I told her I didn’t think that was a good idea. Although interdental and gingival sources of malodor may be transiently improved with antibiotics that suppress bacterial counts, in Jerry’s case I didn’t know what, if anything, I would be treating. “Let me see him in the office again,” I suggested.
The following afternoon both Jerry and Sandy sat in my exam room. When I asked him how he was feeling, Jerry said he was still doing just fine. “But my wife smells ghosts,” he quipped. He and I smiled and looked over at Sandy.
“I am not crazy,” she insisted.
“Of course not,” I said. I asked her if she had noticed changes in the odor of any other things that she smelled—foods, other people’s breath. She shook her head vigorously before I was even done asking the question. “No. It’s not me. I checked.” She went on to tell me that she’d had Jerry take an over-the-counter ulcer medication for a week in case a stomach problem was the cause, but it hadn’t made any difference.
“Not surprising,” I told her. “Halitosis almost never arises from the esophagus, stomach, or intestine.” Undaunted, she repeated, “Something’s wrong.”
I thought for a moment and then said: “Fair enough. You know, sometimes conditions in the lungs can cause the breath to be bad. Let’s do a chest X-ray.” Even though I was certain that the yield on the X-ray would be small, I wanted to be able to tell her we had turned over every stone in search of the cause of Jerry’s nonproblem.
So even though Sandy was the only one who thought her husband’s breath was bad; even though Jerry had no symptoms, findings, or risk factors whatsoever; and even though his lungs had sounded clear when I listened to them at his first visit, I had my medical assistant walk him down the hall for the chest film.
Several minutes later my assistant put the X-ray up on the view box in my office. I took one look and had to suppress an expletive. Sitting in Jerry’s right midlung was a rounded density with a central cavity containing air and fluid. It was the radiographic signature of an abscess.
Amazingly, Jerry had been harboring a chronic infection in his right lung, but it had not been accompanied by any of the typical symptoms of an abscess—fever, cough, sputum production, sweats, and weight loss. He’d had none of them. None, that is, except for an odor on his breath. The smell of purulent sputum incubating deep within a lung may waft its way up the bronchial tree, resulting in serious halitosis. But in Jerry’s case the odor was so subtle that it took the exquisitely sensitive olfactory memory of his wife to pick up the change. The “ghosts” she smelled were real, and antibiotics were exactly what it was going to take to get rid of them.
Adding to my surprise was the fact that Jerry had none of the risk factors associated with a lung abscess. Among patients with intact immune systems (not compromised by HIV or chemotherapy, for example), lung abscesses occur most frequently in those with conditions that impair the swallowing mechanism and allow for the aspiration of food or saliva into the lungs. Disorders such as strokes or neurodegenerative disease and conditions that depress consciousness like alcoholism, seizures, and drug abuse can all predispose to oral contents “going down the wrong pipe.” When coupled with poor dental hygiene, which can lead to the buildup of bacteria, these disorders set people up for aspiration pneumonias, infections that can smolder and destroy normal lung tissue, literally rotting out a “dead zone” in the lung.
But in a small number of cases, lung abscesses may arise in the absence of any identifiable risk factor. It is possible that Jerry had a congenital anomaly in his bronchial tree that led to the pooling of mucus, and eventually to infection, but it is impossible to know for certain.
In the pre-antibiotic era, lung abscesses were fatal one-third of the time and left another third with lifelong debilitating lung disease. The introduction of lobectomy, the surgical removal of part of the lung, improved these numbers, but an extended course of antibiotics long ago replaced surgery as the mainstay of treatment for these infections.
In consultation with an infectious-disease expert, I started Jerry on clindamycin, a potent antibiotic effective against the anaerobic (non-oxygen-consuming) bacteria that most frequently populate this type of infected cavity. After six weeks, an X-ray showed the abscess had shrunk down to a stable and probably permanent scar on Jerry’s lung. There was no reason to expect any recurrence. But had Jerry’s abscess gone undiagnosed, it might well have continued to grow and could have eventually necessitated the surgical removal of part of his lung.
At a visit shortly after finishing the antibiotic course, Jerry told me he had gained new respect for both his wife’s dogged persistence and her uniquely talented nose. Then he said he was considering adding a bit to his stand-up routine about hiring his wife out to the bomb squad at the Los Angeles International Airport. “Or,” I suggested, “maybe you could just get her a bouquet of sweet-smelling flowers and take her out to a nice dinner.”
H. Lee Kagan is a internist in Los Angeles. The cases described in Vital Signs are real, but names and certain details have been changed.