4.5). Breathing his exhaled air from his mouth by closing his nose did not reveal bad breath. Smelling common odors did not reveal any disturbances.
Q1 What was the cause of the patient's halitosis?
1 Early morning halitosis
2 Halitophobia
3 Smoking
4 Drug‐induced
5 Inadequate oral hygiene
Answers:
1 No
2 The fear of having bad breath (halitophobia) was the cause, despite that no one else could notice it. This halitosis is present all day, slightly improved during tooth‐brushing or eating chewing‐gum, causing the patient to brush his teeth and chewing‐gum many times during the day.
3 No
4 No
5 No
Comments: All the other causes of bad breath are easily detected by the people close to the patient, but this did not happen in this case. The early morning halitosis appears in healthy patients only in early mornings, but disappears with teeth brushing or eating breakfast. The absence of smoking or drug use together with the patient's good oral hygiene confirms the fear of non‐existing halitosis.
Q2 What other symptoms accompanied this breath disturbance?
1 Metallic taste
2 Burning sensation
3 Sense of xerostomia
4 Stomatodynia
5 Pruritus
Answers:
1 Taste alteration like metallic taste is a common symptom in patients with severe anxiety, and especially in those with halitophobia.
2 Burning sensation is part of the burning mouth syndrome and often appears together with the delusion of bad breath.
3 The sense but not the presence of dry mouth is a common finding in patients under severe stress, depression, and halitophobia.
4 Stomatodynia is a clinical complaint of patients with severe depression and anxiety and sometimes comes together with halitophobia.
5 Pruritus is a chronic itching of the skin of face and body that is caused by a number of factors among which anxiety plays an important role and is sometimes accompanied with halitophobia.
Q3 Which other conditions have been linked with this condition?
1 Hypochondria
2 Brain tumor
3 Obsessive compulsive syndrome
4 Olfactory reference syndrome
5 Parkinson's disease
Answers:
1 Hypochondria is a somatic symptom disorder characterized by a persistent fear of having an undiagnosed disease which sometimes could cause bad breath.
2 No
3 This disorder is characterized by chronic, uncontrollable thoughts (i.e. worry about bad breath or fear of germs) and continuously repeated behaviors.
4 Olfactory reference syndrome is a psychiatric condition which involves a false belief of an existing body odor that is offensive to other individuals.
5 No
Comments: Both Parkinson's disease and brain tumors cause existing and not hallucinated bad breath, as it is easily detected by other people as a result of xerostomia, poor oral hygiene and main treatment side effects (drugs or surgery).
Case 4.6
CO: A 67‐year‐old woman was presented with multiple bullae on her mouth which could easily break and leave painful ulcerations and bad breath as well.
HPC: The oral lesions appeared one year ago, as flaccid small bullae on the floor of the mouth and buccal mucosae which were easily broken with mastication, thus leaving scattered painful ulcerations. These lesions were accompanied by bad breath.
PMH: Chronic lymphocytic leukemia was diagnosed two months ago and partially responded to two courses of a combined chemotherapy with fludarabine, cyclophosphamide, and rituximab together with plasmapheresis.
OE: Multiple superficial erosions and not intact bullae were found on her palate, floor of the mouth and buccal mucosae. Her gingivae were erythematous, swollen, and bled with probing (Figure 4.6). Nikolsky sign was positive as a small bulla which appeared with gingival rubbing, but is easily broken with slight pressure. Her oral hygiene was poor, causing periodontal problems and caries in her remaining teeth. Gingival biopsy revealed acantholysis at the lower epithelial layers with intra‐epithelial bulla formation and positive immune‐fluorescence (direct and indirect). The bad breath like rotten fruit was obvious and remained unchanged over the days.
Q1 Which is the main cause of her bad breath?
1 Pemphigus vegetans
2 Paraneoplastic pemphigus
3 Benign mucous membrane pemphigoid
4 Caries
5 Periodontitis
Answers:
1 No
2 Paraneoplastic pemphigus was the cause of halitosis. This bad breath was attributed to excessive volatile gas production from numerous pathogenic bacteria which grew within the inflamed oral ulcerations in this woman with a positive history of hematological malignancy.
3 No
4 No
5 No
Comments: The halitosis from pemphigus vulgaris, pemphigoid, or paraneoplastic lesions is indistinguishable and the diagnosis of the responsible bullous disorder should be based on the patient's clinical and histological characteristics, immunological profile and association or not with serious diseases. The bad breath was also reinforced by the patient's chronic periodontitis, caries, and inadequate tooth brushing.
Q2 Which of the neoplasms below is mostly related with this bullous condition?
