|Year : 2021 | Volume
| Issue : 3 | Page : 103-104
The long wait for diagnosis: A rare cause of parotid abscess
S Lakshmi Nair, Monika Khandelwal, Arya Sree Nair, Binshy Latheef, Unnikrishnan Menon
Department of Otorhinolaryngology, Amrita Institute of Medical Sciences, Kerala, India
|Date of Submission||02-Jul-2021|
|Date of Acceptance||02-Sep-2021|
|Date of Web Publication||25-Nov-2021|
Dr. Unnikrishnan Menon
Department of Otorhinolaryngology, Amrita Institute of Medical Sciences, Kerala.
Source of Support: None, Conflict of Interest: None
Bacterial parotitis is most commonly due to oral or dental focus in non-immunocompromised patients. Ultrasonography and guided aspiration are the diagnostic tools, and appropriate antibiotics and supportive medications are the treatment modality. A diagnosis of tubercular parotitis is extremely rare and can be a cause for concern with regard to delayed diagnosis and the possibility of complications. The present case report is about such a case: a young lady with no comorbidities presenting with initial diagnosis of parotid abscess. Evolution and management of the case, with relevant literature, are discussed.
Keywords: Abscess, AFB culture, tuberculous parotitis
|How to cite this article:|
Nair S L, Khandelwal M, Nair AS, Latheef B, Menon U. The long wait for diagnosis: A rare cause of parotid abscess. Amrita J Med 2021;17:103-4
| Introduction|| |
Primary tuberculosis (TB) is most commonly manifested as pulmonary TB and is caused by Mycobacterium tuberculosis. About 20% of cases manifest as extrapulmonary TB, which can affect any organ in the body. TB parotitis is an especially rare presentation. Hence, the diagnosis may be delayed. The present case report looks at such a case and its evolution.
| Case Report|| |
A 21-year-old girl presented with 1-week history of swelling and pain in the left parotid area. It was not associated with history of fever, weight loss, cough, or other significant medical history. As per protocol, she was advised ultrasound scan (USG) neck and salivary glands. This was reported as suggestive of parotid abscess measuring 3.2 × 1.8 cm (6 cc) and multiple level (II, III, IV) hypoechoic lymph nodes on left side. Guided aspiration of fluid was done to harvest fluid for culture. As aspiration from parotid swelling yielded good sample, no further attempts of aspiration were done from lymph nodes. Routine blood investigations (including CBC, ESR, CRP) were also sent. Inflammatory markers were found to be raised. She was started empirically on inj. Piperacillin tazobactum 4.5 g thrice daily, for 1 week inj. Metronidazole 500 mg twice daily, and tab. Linezolid 600 mg twice daily for 7 days. Her symptoms gradually improved. So she was discharged with advice to continue i.v. antibiotics (inj. Piptaz 4.5 g thrice daily) for 2 more weeks.
However, after 3 weeks, she presented with complaints of high grade fever, but resolution of the initial swelling and pain. Clinical examination and investigations (elevated inflammatory markers and procalcitonin with leukocytosis and thrombocytopenia) were suggestive of sepsis. Internal medicine consultation was sought, and accordingly, antibiotics were hiked to inj. Meropenem 1 g thrice daily and inj. Vancomycin 1 g once daily (was continued for about 21 days) along with supportive management. Repeat USG was suggestive of residual parotid abscess measuring 2 by 0.8 cm (4 cc). By then (6 weeks), the initially sent bacterial, fungal, and acid fast bacillus (AFB) cultures were reported negative. On due course, the patient was symptomatically not better and inflammatory markers were rising along with blood picture persistently showing signs of sepsis and multi-organ dysfunction syndrome. She had to be managed in the intensive care as a case of multi-organ dysfunction syndrome. Gradually, she improved and was discharged after 3 weeks. One week later, AFB culture after 8 weeks of incubation turned out to be positive, growing M. tuberculosis complex. The patient was informed regarding this and needed antituberculous regimen and routine follow-ups. Presently, she completed 4 months of ATT and is asymptomatic. There was no clinical swelling, and therefore USG neck was not repeated.
| Discussion|| |
Infection of the parotid gland (parotitis) and parotid abscess are frequently encountered in the ENT department. Some of the common predisposing conditions and precipitating factors are dehydration, malnutrition, poor oral hygiene, dental infection, oral trauma, ductal obstruction including stones, drugs (anticholinergics, antihistamines), chronic diseases (Sjogren’s syndrome, diabetes mellitus), and immunosuppression.
Tubercular parotitis is one of the rare presentations of head and neck tuberculosis, with only approximately 100 cases reported in the literature. The salivary glands are rarely infected by tuberculosis organisms. The explanation is two-fold. One is the continuous flow of saliva that can prevent seeding, and second is the hypothesized protective action of thiocyanate ions and proteolytic enzymes against proliferation of mycobacterium. As such, the exact pathogenesis of tuberculous parotitis remains unclear. The possible mechanisms include hematogenous spread of M. tuberculosis from a distant primary (pulmonary) focus, ascending infection from prior infected cervical lymph nodes through lymphatic route, autoinoculation with infected sputum reaching the gland parenchyma by the afferent lymphatics or by ducts. It usually presents as a chronic form, in which the patient is asymptomatic with gradually growing localized lesion over many years. The acute form manifests as diffuse glandular enlargement within a short period of time and with the features of an abscess. Our case is an example of the latter that later evolved into systemic symptoms.
This case also shows the importance of final report of AFB culture, i.e., after 8 weeks of incubation. As per the Centers for Disease Control (CDC), culture takes anywhere from 4 days to 12 weeks (depending on the method used and how quickly the organism grows). However, an oft-cited article in a Microbiology journal reports that more than 28 days were not necessary to observe growth in any of their cases (58.3% of all mycobacteria were detected within 14 days, 37.5% within 21 days, and 4.2% within 28 days). With regard to starting anti-tuberculous drugs, the protocol is to not wait for culture, but to decide clinically (in case smear is negative). In the present case, it was the reverse; there was no clinical suspicion, and so ATT could be started only after the positive culture report.
| Conclusion|| |
Although rare, tuberculosis should be considered as one of the differential diagnoses of parotid abscess. For the confirmation of this diagnosis, the full microbiological incubation period for AFB culture (8 weeks) should be awaited.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Viselner G, van der Byl G, Maira A, Merico V, Draghi F. Parotid abscess: Mini-pictorial essay. J Ultrasound 2013;16:11-5.
Maurya MK, Kumar S, Singh HP, Verma A. Tuberculous parotitis: A series of eight cases and review of literature. Natl J Maxillofac Surg 2019;10:118-22.
] [Full text]
Chaudhary S. Tuberculosis of the salivary glands. In: Norman JE, McGurk M, editors. Color Atlas and Text of the Salivary Glands. London: Mosby-Wolfe; 1997. p. 337-9.
Sharma S, Dixit R, Dixit K. Tuberculous abscess of parotid gland in an eight year old child. Indian Pract 2008;61:453-6.
https://www.cdc.gov/tb/education/corecurr/pdf/chapter4.pdf (last accessed on June 7, 2021).
Pfyffer GE, Wittwer F. Incubation time of mycobacterial cultures: How long is long enough to issue a final negative report to the clinician? J Clin Microbiol 2012;50:4188-9.