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Case Report

Tuberculous Parotitis

Aygenc, Erdinc MD*; Albayrak, Levent MD; Ensari, Serdar MD*

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Infectious Diseases in Clinical Practice: December 2002 - Volume 11 - Issue 9 - p 555-557
doi: 10.1097/01.idc.0000090386.89010.ae
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Diffuse infective parotitis is common, usually resulting from the mumps, echo, or coxsackie A virus or Staphylococcus in the elderly and debilitated. 1 Tuberculosis in the parotid region, however, is very uncommon, even in countries where the disease is otherwise rife. 2,3 Two pathologic types occur, a common focal form resulting from infection of intracapsular or periglandular lymph nodes and a rare diffuse form resulting from parenchymatous involvement. 1 The clinical picture of patients with disease is a slow-growing parotid mass, clinically indistinguishable from a neoplasm. 2 Most cases were misdiagnosed as parotid tumors, with the diagnosis of mycobacterial infection only after parotidectomy and histopathologic examination. 3,4 If there are no accompanying symptoms, diagnosis of tuberculous parotitis is extremely difficult, and it is often misdiagnosed as a salivary neoplasm or enlarged lymph node of unknown etiology. 5

We present a case of tuberculous parotitis presenting as a parotid mass.

CASE REPORT

A 24-year-old man presented with 3 months history of swelling at the angle of the jaw on his left side. We noted a firm swelling was very painful with palpation. Overlying skin was erythematous and had an irregular surface but was not fixed to his skin. Examination of ear, oral cavity, and pharynx was normal. Fever was noted at 38.5°C. Investigations revealed a white cell count was 12,000 with lymphocyte count was 20%. Erythrocyte sedimentation rate and C-reactive protein concentration were within normal limits. A chest x-ray was normal, but a purified protein derivative reaction was positive. Computerized tomography showed a well-circumscribed 3-cm diameter mass that involved of the superficial of the parotid gland, and it was associated with multiple cervical and parapharyngeal lymphadenopathies (Fig. 1). He had been treated ampicillin-sulbactam combination without improvement before admission to our department. These clinical and laboratory findings suggested that this mass was parotid abscess. We performed incision and drainage of swelling, and the patient was subjected to antimicrobial chemotherapy (ceftriaxone). Smear showed granulomatous inflammation with no organism on gram-stained. The patient did not respond with antibiotic therapy and fistula formation appeared over the incision line. We decided to explore under general anesthesia. Exploration revealed no clear distinction between the mass and the normal parotid tissue. The mass and the superficial parotid tissue were removed with to protect of cervicofacial branch of facial nerve. We also excised overlying skin including fistula. Histopathologic examination showed granulomatous parotitis and reactive lymphoid reaction (Fig. 2). Sections failed to stain for mycobacteria and subsequently grew Mycobacterium tuberculosis in 3 weeks.

F1-6
FIGURE 1:
CT scan view of mass.
F2-6
FIGURE 2:
Granuloma formation (HE × 100).

He gave no personal or family history of tuberculosis, and had no other relevant symptoms (night sweat, weight loss, or pulmonary symptoms). He was treated for tuberculosis of the parotid gland. Antitubercular chemotherapy (ethambutol, rifampicin, isoniazid, and pyranzinamid) was given. His isolate was sensitive for all 4 drugs, so after 2 months of 4-drug therapy, he continued isoniazid and rifampicin for an additional 7 months. At 12 months, there was no local recurrence at the primary site and no evidence of pulmonary tuberculosis. No family member developed tuberculosis in the interim period.

DISCUSSION

Tuberculosis is common in developing countries and, although rarer in the developed countries, has been increasing in recent years. The first description of the parotid gland tuberculosis has been attributed to 2 authors, von Stubenrauch in 1894 and De Paoli in 1896. 6,7 Less than 50% of patients with extrapulmonary tuberculosis exhibit radiologic evidence of pulmonary disease. 2 Infection of the salivary glands and cervical lymph nodes may develop in 2 ways. First, a focus of mycobacterial infection in an oral cavity or mucosal break liberates the mycobacterium that ascends into salivary glands via their ducts or pass to their associated lymph nodes via lymphatic drainage. The second pathway involves hematogenous or lymphatic spread from the lungs. 5,8,9 Two clinical forms of tuberculous parotitis are usually recognized. In one form, an acute tuberculous sialadenitis presents with diffuse gland enlargement. Other form presents as a chronic sialadenitis that manifest itself as an asymptomatic localized lesion within the parotid gland, slowly growing in size for many years. 8 Before pasteurization Mycobacterium bovis was the commonest organism but now it is M. tuberculosis.

Differential diagnosis should include actinomycosis, suppurative parotitis, mumps, sarcoidosis, Sjögren syndrome, sialosis, and neoplasms. 4,10 The definitive diagnosis of tuberculosis depends on the isolation and identification on bacteria from a diagnostic specimen. 10 Recent works advocated the use of fine needle aspiration cytology is useful technique for the diagnosis of tuberculosis of the parotid gland. 2,5,11 Once the diagnosis is made, antitubercular treatment is used. Treatment regimens have 2 phases. Initial (intensive) phase is killing of bacilli and second phase eliminates the remaining bacilli and prevents subsequent relapse. Initial phase takes about 2 weeks, and second phase continues for a longer time.

In our patient, we could found any evidence of active disease elsewhere. Although the consistency of the swelling and the cervical lymphadenopathy could indicate malignancy, other diagnoses of a diffuse swelling with cervical gland enlargement should be considered particularly in young adults with fever. We report this case because of the importance of considering all possible diagnoses, regardless of the rarity of any condition, and any infection that is resistant to antibiotic treatment should alert the physician to suspect tuberculosis and carry out the relevant investigations. We thought that this was of primary nodal disease with secondary spread to the surrounding gland.

REFERENCES

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© 2002 Lippincott Williams & Wilkins, Inc.