Mark Crislip, MD


December 29, 2010


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.

So this was a case of bacterial pneumonia from oral sax.

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.

Addendum February 2, 2011: It has come to my attention that the BMJ article "Unsafe Sax: Cohort Study of the Impact of Too Much Sax on the Mortality of Famous Jazz Musicians" was partly a joke.[4] I thought I got British "humour." However, aspiration from the saxophone playing is still the most likely etiology of this patient's pneumonia.


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