Cervicofacial mycobacterial infections presenting as major salivary gland disease

Cytology as a rapid tool in diagnosing tuberculosis of the parotid gland: A case series with a review of the literature

Tubercular infection of the parotid gland often confuses clinicians, it being a rare entity even in an endemic area. Its similarity in presentation with that of parotid neoplasms, nonspecific symptoms, low incidence and non-contributory radiological findings often leads to its misdiagnosis as parotid neoplasm, which in the due course results in parotidectomy. Therefore, FNAC of parotid swelling is helpful to avoid unnecessary surgery and patient discomfort. We report four cases of FNAC of parotid swelling with suspicion of neoplasm/inflammatory lesion and were diagnosed as tuberculosis of the parotid gland. They were advised antitubercular drugs for 6 months and followed up. These case are reported not just to highlight that parotid is a rare site for tuberculosis, but also to ascertain that FNAC can be an easy and fast diagnostic modality for confirmation of tubercular parotitis rather than going through the long way of resection and confirmation on histopathology.

Surgical management of parotid non-tuberculous mycobacteria lymphadenitis in children: A pediatric tertiary-care hospital's experience

OBJECTIVE

Non-tuberculous mycobacteria (NTM) represents an important etiology of cervicofacial lymphadenitis (CFL) and skin/soft tissue infections in children. It can also affect the salivary glands, including the parotid gland, which is unique due to the presence of intra-salivary lymph nodes. There are no established guidelines for treatment of NTM CFL. NTM lymphadenitis was historically surgically treated; recently the literature supports initial medical treatment. Treatment decisions have been dependent on the extent of disease, preference of providers, and risk of surgical complications. The goal is to report our experience in surgical outcomes of NTM CFL with involvement of the parotid gland after pre-operative medical management.

METHODS

A retrospective case series of patients with NTM affecting the parotid gland at a tertiary care pediatric hospital between 2004 and 2020.

RESULTS

Seventy-two patients were referred for surgical evaluation of possible parotid NTM. Thirty-three patients underwent surgical excision. Fifteen patients were identified with presumed NTM infection involving the parotid gland. There were twelve females and three males with a mean age of 2.0 years (SD 1.55; range 1-6 days) at the time of surgery. All underwent surgical excision with parotidectomy. The most common pre-operative antimycobacterial therapy used was a combination of clarithromycin and rifampin. All 15 patients had pathological findings consistent with NTM infection (granulomatous lymphadenitis). Forty percent (n = 6) of patients had positive stains with acid-fast bacilli (AFB), with Mycobacterium avium as the most common species (n = 5). The majority of patients, 86.67% (n = 13), had complete resolution of infection after surgery. Clarithromycin and rifampin were the most common post-operative antimycobacterial treatment (mean 81.5 days, SD 110.14, range 2-411 days). The most common complication experienced was acute (<3 months) lower facial nerve paresis (40%, n = 6), but no patient had permanent facial paralysis.

CONCLUSION AND RELEVANCE

Parotidectomy is a safe and efficacious treatment in patients with NTM CFL affecting the parotid gland after incomplete resolution with antimycobacterial therapy. Further investigation to optimize duration of antimycobacterial treatment is necessary. We highlight the experience of a high-volume tertiary care pediatric hospital with surgical management of this disease.

A Review of the Microbiology of Submandibular Space Infections

INTRODUCTION

The submandibular space is part of the deep neck fascial spaces. Infection within these spaces can cause significant mortality and morbidity.

MATERIALS AND METHODS

The study is a review of the microbiology of the submandibular space infections seen at the tertiary academic referral hospitals, University of the Witwatersrand. The period of the study is from January 1, 2006, to December 31, 2006. Ninety-three patients were reviewed of which 52 had aspirates taken. The predominant microorganisms were the gram-positive anaerobic cocci. A literature search for this category of infection was also conducted.

CONCLUSION

The most commonly isolated microorganisms were the gram-positive cocci.

Tuberculous Lymphadenitis and Parotitis

Tuberculous lymphadenitis is the most common extrapulmonary manifestation of disseminated tuberculosis (TB). It is considered to be the local manifestation of the systemic disease that has disseminated to local lymph nodes, but a high index of suspicion is needed for the diagnosis, because there are several infectious and noninfectious diseases that can mimic the same clinical picture. In recent years, different diagnostic methods have been introduced, including fine-needle aspiration cytology, which has emerged as a simple outpatient diagnostic procedure that replaced the complete excisional node biopsy, and a number of molecular methods which have greatly improved diagnostic accuracy. This chapter covers the most actual knowledge in terms of epidemiology, clinical manifestations, pathogenesis, and treatment and emphasizes current trends in diagnosis of tuberculous lymphadenitis. TB parotid gland involvement is extremely rare, even in countries in which TB is endemic. Because of the clinical similarity, parotid malignancy and other forms of parotid inflammatory disease always take priority over the rarely encountered TB parotitis when it comes to differential diagnosis. As a result, clinicians often fail to make a timely diagnosis of TB parotitis when facing a patient with a slowly growing parotid lump. This chapter highlights the most important features of this uncommon disease.

Tuberculous Parotitis: Case Report and Literature Review

Objectives:

Our aim was to better understand the rarely encountered tuberculous (TB) parotitis.

Methods:

A case of TB parotitis is reported, and the literature is reviewed.

Results:

Forty-nine patients (27 men, 22 women; mean age, 38.3 ± 16.4 years) were enrolled. The median duration of symptoms before these patients sought medical help was 6 months. Except for 1 patient with bilateral TB parotitis, all had unilateral involvement; complications included draining sinuses in 4 patients (8%) and facial palsy in 2 patients (4%). Twenty-one of 36 patients (58%) had a painless parotid mass, 12 of 19 (63%) had cervical lymphadenitis, 8 of 11 (73%) had fever, and 11 of 44 (25%) had pulmonary tuberculosis (4 active and 7 inactive cases). Neoplasm was the most common presumptive diagnosis. The diagnosis of TB parotitis in most cases was made on the basis of cytologic analysis of the fine-needle aspirate or histopathologic analysis of the excised tissue. Forty-six patients with TB parotitis who had a traceable outcome survived after 6 to 10 months of antituberculosis chemotherapy.

Conclusions:

Physicians should have a high index of suspicion for TB parotitis in patients with a chronic parotid lump, even if the chest radiographs appear normal. Fine-needle aspiration should be performed first for diagnosis, and TB parotitis should be medically treated.

Head and neck tuberculosis: 6-year retrospective study

INTRODUCTION

Pulmonary involvement exists in 80% of cases of infection with Mycobacterium tuberculosis; however, in up to 20% of cases there may be extra-pulmonary involvement. In the ENT area, the most common site is cervical lymphadenitis, affecting approximately 95% of cases.

MATERIALS AND METHODS

This was a retrospective study of patients attending an ENT department in a tertiary hospital for head and neck symptoms that were diagnosed with tuberculosis (TB), between December 2007 and December 2013.

RESULTS

The study included 73 patients, 41 (56.2%) males and 32 (43.8%) females (M/F ratio=1.28), with a mean age of 39.4 years (± 26.5 years; Min 1, Max 88). There were 53 (72.6%) cases of cervical lymphadenopathy, 11 (15%) of laryngeal tuberculosis 3 (4.1%) of hypopharyngeal tuberculosis, and six cases in other locations. Of the total, 14 (19.2%) patients were HIV positive and 10 (13.7%) had a history of contact with relatives who had suffered pulmonary tuberculosis. PCR was performed in 51 (69.8%) cases to confirm being positive, of which 47 (92.1%) cases were.

CONCLUSION

The similarity of tuberculosis to diseases of poor prognosis and the difficulty of its diagnosis make considering tuberculosis necessary when exploring patients with ulcerative or granulomatous ENT lesions. Analysing our results, the incidence of TB according to its ENT area location is similar to that reported in the literature. It is important to make special mention of the use of PCR in our study and the benefits that its implementation means for diagnosis.

Bilateral parotid tuberculosis

Tuberculosis of parotid is a rare clinical entity, and cases of bilateral tubercular parotitis are even rarer. We present a case of bilateral primary parotid tuberculosis in a 49-year-old female. The patient received anti-tuberculosis treatment for six months, resulting in complete resolution of the disease. We also review the theories related to the pathogenesis of tubercular parotitis, and propose a novel hypothesis about greater involvement of parotid gland as compared to other salivary glands in primary tuberculosis.

Tuberculosis of the parotid gland

The presentation of tuberculosis as an isolated parotid lump is rare. In this paper, six cases with tuberculous parotitis are reported which were evaluated as a benign parotid neoplasm in 216 specimens pre-operatively. All but one of them had no previous history of tuberculosis and all had a parotid lump as a sole symptom for at least one year. The diagnosis of tuberculosis was made, after superficial parotidectomy, by histopathology. Parenchymal involvement and intraparotid lymph node involvement with tuberculosis were seen in five and three patients, respectively. Two of the patients had lymph node involvement outside the parotid area. One of six patients had a coincidental Warthin tumour. A surgical approach is not only therapeutic but also diagnostic when other diagnostic tools fail.

Mycobacterium fortuitum-induced persistent parotitis: successful therapy with clarithromycin and ciprofloxacin

BACKGROUND

Parotitis caused by nontuberculous mycobacteria, a very rare disease entity, has never been reported to be caused by Mycobacterium fortuitum (M. fortuitum) in the literature.

METHODS AND RESULTS

An 8-year-old girl was seen with painful swelling of the right parotid gland despite antibiotic treatment of more than 1 month. Elevated serum amylase activity and diffuse contrast-enhanced CT of the parotid gland confirmed the diagnosis of parotitis. Histopathological study of specimens taken from the right parotid tail mass showed granulomatous inflammation with acid-fast positive bacilli; culture later confirmed M. fortuitum. After administration of clarithromycin and ciprofloxacin for 9 consecutive months, the parotitis and parotid tail mass were completely resolved at follow-up examination.

CONCLUSION

To our knowledge, this is the first case report of parotitis caused by M. fortuitum and its successful medical treatment.

Bilateral parotid gland tuberculosis

Tuberculosis is caused by a mycobacterium and is one of the most serious diseases in the world. Pulmonary involvement is the most common form of this condition. Primary tuberculosis of the parotid gland is rare. We report such a case in a 34-year-old man who presented with a painless preauricular mass on each side of his head. The clinical presentation, diagnosis, pathological findings and treatment are described.

Atypical mycobacterial cervicofacial lymphadenitis in children: a disease as old as mankind, yet a persistent challenge

The diagnosis of atypical cervicofacial lymphadenitis is often not readily clinically apparent. Parents may bring a child to the physician's attention long before the development of the classic findings. When assessing the child with acute-onset cervicofacial lymphadenitis, there are 2 imperative clinical determinations: Is the lymphadenitis of viral, bacterial, or mycobacterial etiology? If of mycobacterial etiology, is it an atypical or tuberculous mycobacterial process? The goal in management is to avoid misdiagnosis and lengthy duration of symptoms before appropriate therapy is instituted. This paper includes a case study-based review of the evaluation, diagnosis, and management of cervicofacial lymphadenitis in children due to atypical mycobacterial organisms.

Nontuberculous mycobacteria-induced parotid lymphadenitis successfully limited with clarithromycin and rifabutin

OBJECTIVES/HYPOTHESIS

Nontuberculous mycobacterial adenitis of the parotid gland is often difficult to diagnose. The rarity of these infections in the parotid region and the lack of specific guidelines pose a treatment challenge to the clinician. Three cases of nontuberculous mycobacterial adenitis are presented, with clinical response to antibiotics before surgery.

STUDY DESIGN

Retrospective chart review was made of children up to 18 years of age presenting with a parotid mass diagnosed as nontuberculous mycobacterial infection.

METHODS

Three patients (age range, 15 to 30 mo) with nontuberculous mycobacteria-induced parotid lymphadenitis were treated with a combination antibiotic regimen of clarithromycin and rifabutin or with clarithromycin alone.

RESULTS

All three patients responded clinically to the antibiotic treatment as evidenced by a smaller mass size and resolution of the overlying discoloration. Subsequent parotidectomy or biopsy appeared to be easier to perform because of decreased inflammation and edema and a more readily dissectible facial nerve.

CONCLUSION

Children with nontuberculous mycobacteria-induced parotid lymphadenitis should be started on a trial of antibiotic treatment before surgery. Although surgery remains the definitive treatment modality, a larger study of preoperative antibiotic use against nontuberculous mycobacterial adenitis of the parotid in children is necessary.

Nontuberculous mycobacterial cervical adenitis: a ten-year retrospective review

OBJECTIVE

To review the authors' institutional experience with nontuberculous mycobacterial cervical adenitis in children over a 10-year period.

STUDY DESIGN

Retrospective chart review.

METHODS

The case histories of 79 children with nontuberculous mycobacterial lymphadenitis who presented to a large tertiary care referral center from 1989 to 1999 were retrospectively analyzed, and the demographics, clinical presentation, methods of diagnosis, and types of surgical intervention they underwent were reported.

RESULTS

The mean age at presentation was 3.6 years. The male-to-female ratio was 1:2, and the frequency of presentation was highest in the winter and spring months. The diagnosis was not immediately apparent to most primary health care physicians because there was a delay between the appearance of the lump and referral for treatment, which was in excess of 8 weeks. Involved nodes were mainly treated surgically. The recurrence rate of complete surgical resection was less than 1%.

CONCLUSION

The study highlights the fact that a high index of clinical suspicion is needed to make an early diagnosis of nontuberculous mycobacterial lymphadenitis and lends further weight to the already existing evidence that surgical excision remains the mainstay of successful treatment for lymphadenitis caused by nontuberculous mycobacteria.

Re-emergence of tuberculosis and its variants: implications for dentistry

Tuberculosis is one of the deadliest scourges of mankind and, overall, one third of the global population is infected with this mycobacterium or its variants. The advent of the human immunodeficiency virus (HIV) pandemic has accelerated its spread inexorably whilst the multi-drug resistant strains of the bacillus have hampered disease management. Given the alarming spread of the disease, there appears to be a significant potential for occupationally acquired tuberculous infection amongst health care workers, including dental care workers. This review addresses the basic microbiology and the pathogenesis of tuberculosis, its oral manifestations, mycobacteria other than tuberculosis (MOTT), multi-drug resistant tuberculosis (MDR-TB), management including aspects of the global programme on tuberculosis (DOTS programme), the potential for occupationally acquiring the disease and finally, the infection control measures that are available for dental and other health care workers.

Imaging of granulomatous lesions of the neck in children

Cervical lymphadenopathy is the most common presentation of granulomatous inflammation of the neck in children and is usually caused by NTM infection. Although certain granulomatous infections have characteristic imaging features, there is considerable overlap in the imaging appearance of the various disorders. The diagnosis is usually based on a combination of clinical features, histopathologic examination, serologic tests, and culture results.

Mycobacterial disease of the parotid gland

Mycobacterial disease is an unusual but important condition that should be considered in the differential diagnosis of a discrete parotid gland swelling or mass. The management of this condition involves exclusion of neoplastic disease and combined medical and surgical therapy. We present 5 cases of mycobacterial involvement of the parotid gland and discuss issues surrounding the diagnosis and treatment options.

Polymerase chain reaction in the diagnosis of parotid gland tuberculosis

A parotid gland mass with presenting features of malignancy is a diagnostic and therapeutic challenge. The histological nature of the lesion must be clearly determined before proceeding with facial nerve sacrificing surgery. Although rare, tuberculosis of the parotid gland must be included in the differential diagnosis of a parotid gland mass especially when the social characteristics of the patient suggests a mycobacterial infection. Primary tuberculosis of the parotid gland is generally encountered among populations with a high incidence of pulmonary disease. The difficulty in the differential diagnosis of a parotid gland malignancy may be helped by a high degree of clinical suspicion, since laboratory tests generally do not identify the specific causative organism. This article reports the first case of parotid gland tuberculosis with clinical and radiodiagnostical features simulating malignancy in which the diagnosis was confirmed by the polymerase chain reaction (PCR).

Tuberculous parotitis: a case report

Tuberculosis of the parotid gland is rare. It cannot be distinguished d form a parotid tumour by clinical examination alone, so surgical exploration has usually been required for diagnosis. We present a case with the same diagnostic dilemma.

Surgical treatment of cervicofacial nontuberculous mycobacterial adenitis in children

Fifteen children with nontuberculous mycobacterial adenitis of the head and neck underwent surgical treatment between July 1991 and July 1994. Fine-needle aspiration for biopsy and culture allowed early diagnosis in nine children. Positive cultures grew Mycobacterium avium-intracellulare complex in 12 children and M. chelonei in one child. Total excision was performed in 10 cases with combinations of lymphadenectomy and salivary gland excision. Curettage was used to successfully treat five children. One patient required local flap coverage for primary wound repair. Two patients required more than one surgical procedure. Our approach to early diagnosis and surgical treatment of cervicofacial nontuberculous mycobacterial adenitis is presented.

Mycobacterial cervical lymphadenitis. A clinicopathological study of 3 cases

Three adult patients with tuberculous cervical (submandibular) lymphadenitis were treated in the past year in the Department of Oral and Maxillofacial Surgery, Evangelismos Hospital, University of Athens. None had a history of exposure to tuberculosis. In all, the chest X-rays were clear but the PPD tests were positive. All patients underwent excisional biopsy of grossly involved lymph nodes and histological examination and special stains confirmed the diagnosis. The patients were subsequently treated with triple drug administration. Antituberculosis chemotherapy consisted of isoniazid, rifampin and ethambutol and all are well after a follow-up of 9, 10 and 11 months respectively. Medical approaches often failed to diagnose tuberculous cervical lymphadenitis conclusively, and this disease remains a diagnostic and therapeutic challenge, because it mimics other pathological processes. The treatment of choice seems to be surgical excision and long term antituberculosis chemotherapy. Surgery provides a rapid tissue diagnosis, because the histological examination of the excisional biopsy is the most reliable diagnostic test.

Diagnostic and therapeutic management of atypical mycobacterial infections in children

A series of 12 children (9 girls, 3 boys) with non-tuberculous mycobacterial lymphadenitis was reviewed to define the most frequent presenting features, helpful diagnostic measures and optimal management. The mean age at diagnosis was 42 months and cervical nodes in the submandibular region were most commonly affected. In most of the children the diagnosis was made on the basis of a positive intradermal skin test with specific antigens for atypical mycobacteria. The diagnosis was confirmed in all but one case by histopathologic examination. Total excision of the affected gland was recommended as the therapy of choice in the patients treated.

Mycobacterial infections of the head and neck

Despite the decline of pulmonary tuberculosis in the Western world, the incidence of cervical mycobacterial infections has remained relatively unaffected. A retrospective review was conducted of 20 patients treated for head and neck tuberculosis from 1984 to 1991. They were mostly an immigrant group coming from underdeveloped countries close to the equator. All cases were treated with antituberculous chemotherapy; 18 patients also underwent surgical excision of their lymphadenopathy. Sixteen patients showed complete response to combined treatment and one relapse was successfully retreated with antituberculous medication. Three patients died from unrelated causes--two from human immunodeficiency virus infection and one from nasopharyngeal carcinoma. The most reliable indicator of mycobacterial infection was the pathologic specimen, making the need for surgical intervention an important diagnostic consideration. As with other reports, most patients in our series had negative chest x-ray films, variable responses to skin testing, and negative cultures. The epidemiology, pathogenesis, and management of this disease are discussed.

Diffuse tuberculous parotitis

Parenchymatous parotid tuberculosis diffusely affecting the entire gland is very rare. We present a case, associated with a primary pulmonary focus, that was confirmed after positive identification of alcohol and acid-fast bacilli in gastric washings. Both sites of infection resolved with quadruple anti-tuberculous chemotherapy.

Granulomatous sialadenitis

Granulomatous inflammation in salivary tissues is most often a response to liberated ductal contents, particularly mucin, in various degrees of obstructive sialadenopathy. Far less often is a granulomatous sialadenitis the result of specific infective granulomas or systemic granuloma-forming diseases. In these instances, the salivary parenchymal involvement is usually secondary to disease localization in regional lymph nodes.

Atypical mycobacterial infection of the parotid gland

A localized atypical mycobacterial infection of the major salivary gland is a rare disease. In this report the cases of three patients with this lesion are presented. The diagnosis was based on the clinical picture, skin testing with specific antigens, bacteriologic culture, and histopathologic findings. The patients were successfully treated by total parotidectomy with facial nerve preservation, which in our opinion is the therapy of choice in localized atypical mycobacterial infections.

Mycobacterium tuberculosis cervical adenitis. Diagnosis and management

Cervical adenopathy as the sole presentation of tuberculosis is seen infrequently in the pediatric age group. Despite modern treatment and public health measures, tuberculous cervical adenitis persists, and its prompt diagnosis and treatment are important from both a clinical and preventive health perspective. The authors report five cases of children with ages ranging from 8 to 17 years, in whom cervical adenitis was the only presentation of infection with Mycobacterium tuberculosis. The clinical presentation and methods of diagnosis and treatment are described, and the difficulty of differentiation between infections with M. tuberculosis and non-tuberculous mycobacterial infections is stressed. Tuberculous cervical adenitis should be considered in cases of an elusive diagnosis of a cervical mass in the pediatric patient.

Scrofula revisited

Mycobacterial cervical lymphadenitis, or scrofula, is a disease dating back thousands of years. In spite of modern treatment and public health measures, scrofula persists but is infrequently seen. Five patients with cervical tuberculous lymphadenitis as a sole presentation have been seen in our department in the last 10 years. The clinical presentation and current methods of diagnosis and treatment are described. A short historical review is given.