What Causes Bromhidrosis?

Patient Presentation
A 14 month-old female came to clinic with a complaint of body odor. The parents state that it did not occur when she was first born, but started sometime in the next few months. They state that they can bathe her daily in the evening and within 20-30 minutes she will begin to smell like sweat. The smell does not change. Parents states that it will be worse at certain times such as before a bath, but it does not change over the day, nor is it overpowering. Occasionally, other people will comment about the smell but usually it is not a problem. The parents deny having a problem with body odor themselves. The mother says that she wears perfume regularly because she likes the smell, not to cover up body odor. They eat an American diet without many spices, onions, garlic or other heavily scented foods. She had two ear infections in the past that she took amoxicillin for but was not on any medications currently. The parents deny her placing any foreign objects into an orifice, and also deny discharge or odor coming from an orifice.

The past medical history reveals a healthy toddler, born at term, with a confirmed normal neonatal screening test that included tandem mass spectrometry.

The family history is negative for any genetic or metabolic abnormalities. The parents deny consanguinity, nor a family history of miscarriages, early deaths or unexplained deaths.

The review of systems was normal.

The pertinent physical exam showed a happy toddler with growth parameters in the 75-90%. She did have a smell of sweat in general, that was not localizable. It was not from the urine in her diaper as when the diaper was separated from her in the room, the smell remained with the child. Her examination was normal including normal skin examination (especially all intertrigenous areas) and she was Tanner stage 1 for breast and hair.

The work-up previously done by another health care provider included a normal complete blood count, thyroid function testing, urinalysis and lead. As the child showed normal growth and development with a normal neonatal screening, and no specific history of various causes, the diagnosis of idiopathic bromhidrosis was made. The natural history of the problem was discussed with the family. The parents were told they could try an antipersperiant that contains aluminum salts. They were instructed to apply only to non-broken skin and to not allow the child to ingest the material or inhale the antiperspirant. They were also offered the option of a consultation with a dermatologist. They wanted to try the antiperspirants first.

Discussion
Bromhidrosis or body odor is common in post-pubertal individuals because of apocrine gland secretions and increased exertion. It usually is self-limited or easily controlled. Sometimes it becomes more chronic, difficult to control and can affect a person’s quality of life. It is found in all races and genders.

Eccrine secretory glands are found over the entire body service and assist in thermoregulation through sweating. Normally sweat is odorless. Softening of keratin and bacterial decomposition causes an odor. Certain foods, drugs/toxins or metabolic products may be secreted into the eccrine sections causing odor.

Apocrine secretory glands are found in the axilla, breast, genital skin and periorbital and periauricular areas. They cause characteristic pheromonal odors. Apocrine bromhidrosis is the most common form of bromhidrosis. Bacterial decomposition of apocrine secretions changes the secretions into volatile acids and ammonia.

Hyperhidrosis or excessive sweating may potentiate bromhidrosis. Potentially apocrine hyperhidrosis may contribute to bromhidrosis by creating a wet environment that facilitates bacterial overgrowth and also spreading of the secretions. However eccrine hyperhidrosis may also flush away secretions faster, therefore decreasing bromhidrosis.

Learning Point
Causes of bromhidrosis include:

• Apocrine bromhidrosis and hyperhidrosis
• Eccrine bromhidrosis
  • Foods
    • Alcohol
    • Curry
    • Garlic
    • Onion
  • Drugs
    • Penicillin
    • Bromide
  • Metabolic disorders
    • Phenylketonuria
    • Trimethyaminura (fish odor)
    • Sweaty feet syndrome
    • Cat odor syndrome
    • Isovaleric acidemia
    • Hypermethioninemia
• Inadequate hygiene with bacterial overgrowth
  • Diabetes
  • Erythrasma
  • Intertrigo
  • Obesity
  • Trichomycosis axillaris
• Foreign body in an orifice
• Mistaken odors- tobacco smoke, perfume, asparagus smell of urine after ingestion

Questions for Further Discussion
1. What is the differential diagnosis for abnormal smelling urine?
2. What is the differential diagnosis for halitosis?

Related Cases

Disease
Bromhidrosis
Sweat

Symptom/Presentation
Sweating

Specialty
General Pediatrics
Dermatology

Age
Toddler

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Sweat

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

MacFarlane A, Knass D, Beardwell CG,Shalet SM.
Hyperhidrosis in acromegaly: effectiveness of topical aluminum chloride hexahydrate solution Br. Med. J.; VOL 2 ISS Oct 13 1979, P901-90.

Rehmus W, Brown K. Bromhidrosis. eMedicine.Available from the Internet at http://emedicine.medscape.com/article/1072342-overview (rev. 2/16/2007, cited 3/25/09).

ACGME Competencies Highlighted by Case