BACKGROUND Trimethylaminuia is an unusual observation, often termed fish odor syndrome. The condition results from reduced ability to oxidize trimethylamine (TMA), which has a fishy odor, into odorless trimethylamine N-oxide (TMAO). METHODS Proton nuclear magnetic resonance spectroscopy (MRS) was used as a simple and rapid method to detect TMA and TMAO in the same urine sample without pretreatment. Subjects were considered to have deficient N-oxidation of TMA if the TMAO/TMA ratio was greater than 80 p. 100 (heterozygous) or 65 p. 100 (homozygous). CONCLUSIONS Direct proton RRS analysis of urine is well suited for diagnosis of fish odor syndrome. It can be used to detect heterozygous patients and also provides an easily implemented follow-up tool.