After smoking or inhaling marijuana, the onset of symptoms is rapid (within to 30 minutes), with the duration of effects for several hours In contrast, after ingestion of marijuana edibles, the onset of symptoms is much slower (1 to hours) with several hours’ duration The most common overdose incidents in children occur with edibles and can have a more severe and prolonged effect because of the variable amounts of THC Young children may mistake edible marijuana products for regular food or candy and ingest it unknowingly Small children are at higher risk based on their size and weight Many young children who consume marijuana edibles require hospital admission because of the severity of their symptoms Salicylates are ubiquitous agents found in hundreds of over-the-counter (OTC) medications and in numerous prescription drugs, making salicylate toxicity an important cause of morbidity and mortality Methyl salicylate (oil of wintergreen) or topically applied products may provide an early clue indicative of methyl salicylate poisoning by the pleasant minty smell of wintergreen This can prompt the astute clinician to immediately institute lifesaving therapy A strong garlic odor is typical of arsenic, arsine gas, phosphorus, tellurium, parathion, malathion, selenium, dimethyl sulfoxide, and thallium The odor of bitter almonds or peach pits is indicative of cyanide poisoning, in which the degree of excretion of the odor parallels toxicity (although the ability to detect this odor is genetically determined and may only be present in up to 40% of persons) Turpentine can be identified by the bouquet of violets Diagnostic odors are found in several sedative-hypnotic medications that primarily have central nervous system manifestations Ethchlorvynol (Placidyl) is a volatile agent that has an aromatic plastic or vinyl-like breath odor Ingestion results in coma, hypothermia, respiratory depression, hypotension, and bradycardia An overdose of chloral hydrate can result in central nervous system depression ranging from slurred speech, ataxia, and incoordination to deep coma, gastritis, and cardiac arrhythmias It may be seen in children or as an intentional overdose in adults, and it imparts a fruity, pearlike scent Disulfiram (Antabuse) gives the breath a rotten egg odor because of the sulfide metabolites Additional odors from toxins are listed in Table 50.1 Infectious Diseases Many microorganisms produce characteristic odors that suggest the diagnosis of their respective infectious diseases by olfaction alone ( Table 50.1 ) Omphalitis in the newborn can be life threatening It presents with a foul or putrid odor associated with a draining, erythematous umbilical area Less common infections that have been historically associated with characteristic odors include typhoid’s aroma of freshly baked bread, yellow fever’s butcher shop smell, smallpox’s menagerie odor, scrofula’s odor of stale beer, diphtheria’s sweet smell, and rubella’s scent of freshly plucked feathers Medications also have distinguishing odors Penicillins give off an ammoniacal scent, whereas cephalosporins are noted to have a musty odor Topical benzoyl peroxide, applied in large quantities, emits a pungent, pervasive aroma Dermatologic Conditions Many dermatologic diseases ( Table 50.1 ) are associated with specific odors Any cause of hyperhidrosis results in an offensive body odor Hidradenitis has a characteristic pungent odor, and Darier disease (keratosis follicularis) is noted to have a pervasive aroma of burned tissue An abscess or cellulitis is identified by the characteristic odors of the responsible microorganisms In burn patients, there is the typical odor of charred flesh, which, when infected with Pseudomonas aeruginosa, takes on a characteristic sweet, grapelike odor Foreign Bodies Foreign bodies can produce a foul odor that results from secondary bacterial colonization or infection Foreign body odors can be localized to a particular orifice, or they may pervade a patient’s clothing, body, and surrounding environment Foul-smelling, fetid, or feculent odors indicate anaerobic infections, a sickly sweet odor is associated with Escherichia coli, and a mousy odor is associated with Clostridium Orifice Odors Specific orifice odors can be diagnostic of infectious disease processes Oropharynx A healthy mouth does not give off an offensive odor Halitosis, or bad breath, is the result of a release of volatile sulfur compounds formed when the oral flora metabolizes amino acids from compounds in the saliva that adhere to the tongue, teeth, and gums Halitosis is increased in states of diminished solid and liquid intake Tonsillitis (see Chapter 74 Sore Throat ) has an offensive odor, and group A β-hemolytic streptococcus gives off a characteristic “strep breath” smell Dental abscesses (see Chapter 117 Dental Emergencies ), gum or periodontal disease, and acute ulcerative gingivitis (Vincent angina, or trench mouth) are associated with a penetrating, offensive odor often described as metallic in nature The oropharynx is also the portal of exit for deeper infections Lung abscesses, empyema, bronchitis, and bronchiectasis result in foul breath and sputum Nasal foreign bodies in toddlers are usually associated with an odor identified by parents as bad breath Nose Nasal drainage can be clear and odorless or mucopurulent and odiferous Nasal drainage and bleeding can reflect local infections, foreign bodies, irritations of the nasal passage, and sinus drainage Ear Sterile inner ear fluid is odorless but gives off a rank smell when infected Acute otitis externa is usually associated with a mucoid drainage, whereas chronic otitis externa produces a purulent, discolored drainage with a foul odor, usually caused by P aeruginosa or Staphylococcus aureus Genitalia Vaginal secretions are combinations of vulvar secretions from sebaceous, sweat, Bartholin and Skene glands, transudate through the vaginal wall, exfoliated cells, cervical mucus, endometrial and oviductal fluids, plus vaginal microorganisms and menstrual blood These secretions are hormonally mediated and vary with the menstrual cycle Odors are exacerbated by the presence of retained foreign bodies, including tampons and diaphragms Bacterial vaginosis (nonspecific vaginitis, Gardnerella vaginitis, Corynebacterium vaginitis, Haemophilus vaginitis, nonspecific vaginosis, and anaerobic vaginosis) is caused by an increase in anaerobic bacteria and a decrease in lactobacilli (see Chapter 92 Gynecology Emergencies ) The anaerobic bacteria act synergistically with Gardnerella vaginalis to produce enzymes and aminopeptidases that degrade proteins, and decarboxylases that convert amino acids and other compounds to amines The amines produce the characteristic “fishy” odor, which is best detected by alkalinization using 10% potassium hydroxide placed directly on a vaginal swab and smelling immediately This odor also can be indicative of sexual abuse in children Vaginal infection with Trichomonas often is associated with a fishy odor, whereas Candida vaginitis is notably free of odor A male counterpart, balanoposthitis, is associated with a urethral discharge that produces a fishy odor when alkalinized because of the same process and organisms that occur in bacterial vaginosis Urethral Meatus A urinary tract infection caused by urea-splitting bacteria will emit an ammoniacal odor Rectum Stool odors vary with diet, medications, and microbiologic flora Various malabsorptive syndromes, such as sprue, cystic fibrosis, and Whipple disease, are associated with foul-smelling stool The blood in the stool has a distinctive pungent odor, as does the pus Shigella and Salmonella have distinctive rank odors Systemic Diseases Several nutritional syndromes ( Table 50.1 ), such as pellagra’s stench of sour or musty butter and the putrid or fetid smell of scurvy and gout, have unique odors Schizophrenia has a characteristic body odor described as heavy, unpleasant, and pungent The odor-producing substance is trans- 3-methyl-2-hexenoic acid, which is produced in the sweat Uremic breath is produced by secondary and tertiary amines, dimethylamines, and trimethylamines that produce a fishy odor Malignancy, especially when associated with an expanding external mass, bleeding, and necrosis, gives off a trenchant odor because of tissue and cellular breakdown plus gas formation Hepatic failure gives an odor of “fetor hepaticus” (described as musty, rotten eggs, or garlic) and is noted in the breath or urine In Crohn disease, the development of gastric fistulae is often heralded by a feculent odor