05-08-17 Is That Smell Significant?

Toxicology Question of the Week

May 8, 2017

Is that Smell Significant?

Sniffing, Sniffing with your nose

May help you treat your patient’s woes.

Don’t disregard that strange smell,

‘Cause there’re secrets it could tell.

            The smells of outdoor grills, fresh cut grass, nearby skunks, and freshly fertilized fields are filling the air, indicating that spring has arrived.  Complex olfactory senses help individuals perceive the world around them, and they periodically assist healthcare professionals in the clinical setting.  For centuries, the sense of smell has been a key diagnostic tool in the practice of medicine.  Often, the “nose” is a crucial part of many diagnoses.  Several infectious diseases and metabolic ailments have characteristic odors.  These odors may present as unusual body, breath, urine, or vaginal aromas.  In addition, some intoxicants can generate distinguishing odors after specific drug and chemical exposures.  Odor recognition enables clinicians to rapidly detect certain toxic emergencies before laboratory identification or clinical confirmation occurs.  Familiarity with the potential odors released during these emergencies may lead to earlier treatment initiation; however, odor differentiation usually requires teaching and practical experiences.  Some of the common odors detected in the toxicology field that give rise to great concern include:

 1) ACETONE (SWEET, FRUITY)                                   15) PEANUTS 

 2) ACRID (PEAR-LIKE)                                                 16) PEARS

 3) AMMONIACAL                                                       17) PEPPER

 4) BANANAS                                                               18) PUNGENT-AROMATIC 

 5) BITTER ALMONDS                                                             19) ROPE (BURNED)

 6) CARROTS                                                               20) ROTTEN CABBAGE

 7) COAL GAS (STOVE GAS)                                         21) ROTTEN EGGS

 8) DISINFECTANTS                                                      22) SHOE POLISH

 9) FISH OR RAW LIVER (MUSTY)                               23) TOBACCO  

10) GARLIC                                                                  24) VINEGAR

11) HAY                                                                       25) VINYL

12) MEDICINAL                                                           26) VIOLETS

13) METALLIC                                                             27) WHITE PASTE 

14) MOTHBALLS                                                         28) WINTERGREEN

Thus, if a local farmer arrives in the emergency department around midnight, suffering from symptoms of:

1) severe sunburn to his face, arms, and upper torso,

2) itchy, red, watery eyes with dilated pupils,

3) profuse diaphoresis, 

4) persistent nausea, vomiting, and diarrhea

5) a strong garlic odor on his skin and in his emesis, and

6) a triage history of:

a) spending the entire windy day spraying his crops with an insecticide

b) taking Benadryl at 9am, 3pm, and 9pm for treatment of his hay fever, and

c) eating around 6pm at his church’s potluck Italian Feast dinner, at which he had:          

   i) large amounts of garlic bread,

  ii) spaghetti and meatballs with tomato sauce and Parmesan cheese,

 iii) sausage, green peppers, and onions in an oregano and garlic broth

iiii) several glasses of sweet tea,

then the initial assumption might be that he is suffering from food poisoning, but ruling out other potential diagnoses, both medical and toxicological, is vital.  From the poison center point of view, there are more than 12 harmful substances that will generate a garlic odor.  Therefore, evaluating him for possible arsenic or organophosphate poisoning as well as several other potential hazards would be prudent.

So, next time you have a patient secreting an unusual odor and you question, “Does that smell have any toxicological significance?” feel free to call the Poison Control Center to discuss the matter, especially if the odor fits into one of the categories above.   The Poison Control Center is open 24/7/365, and specialists are always willing to assist when needed. As the saying goes:  just follow your nose.

References:

>Micromedex @www.micromedexsolutions.com

>Diagnostic Odor Recognition. Academic Emergency Medicine 7(10): 1168-9. November 2000

>News for Nose: Machines Use Odor to Diagnose Disease by Douglas McCormick, 17 Sep. 2013 @ www.spectrum.ieee.org

>Smelling the diagnosis: a review of the use of scent in diagnosing disease. Bijland, Bomers, & Smulders. Neth J Med, 2013 Jul-Aug 71(6): 300-7, PubMed

This Question prepared by:  Cheri Wessels, RN, BSN, MBA, CSPI

I am interested in any questions you would like answered in the Question of the Week.  Please email me with any suggestion at donna.seger@vanderbilt.edu

Donna Seger, MD

Medical Director

Tennessee Poison Center

www.tnpoisoncenter.org

Poison Help Hotline: 1-800-222-1222

The Question of the Week is available on our website: www.tnpoisoncenter.org