Deep neck infection in elderly patients. A single institution experience (2000–2004)

BACKGROUND AND AIMS

Immunosenescence, the age-related decline in immunologic function in healthy individuals, seems to contribute to increased susceptibility to bacterial infections in the elderly population. The present study describes elderly patients' susceptibility to deep neck infection and prognosis.

METHODS

Between January 2000 and March 2004, 103 patients were admitted to the Department of Otolaryngology, University of Padova for deep neck infection. Twenty-four patients (23%) were over 65 (elderly patients). The remaining 79 patients (77%) aged < or =65 years (adult non-elderly patients) were also studied. Presentation modalities, origin of infection, site of deep neck infection, radiological investigations, bacteriology, treatment and outcome were all studied.

RESULTS

Hypertension and diabetes mellitus were the most commonly associated systemic diseases in both elderly and non-elderly patients. The number of patients with associated systemic diseases was significantly higher in the elderly group. The most common cause of deep neck infection was dental infection in both age groups. In the elderly group, salivary gland origin had the same incidence as dental origin. Twenty-two patients (6 elderly patients) were treated only with intravenous antibiotic therapy and intravenous steroids. Overall, in 81 cases (78.6%) (18 elderly patients) medical plus surgical procedures were indicated. None of the treated patients died of deep neck infection or its complications.

CONCLUSIONS

Although the incidence of associated systemic diseases and complications of deep neck infections were higher in the elderly group, our medical or medical plus surgical approaches to deep neck infections, based on clinical and radiological evidence, were successful in all patients treated.

Two cases of parotid gland infection with bacteraemia due to meticillin-resistant Staphylococcus aureus

Parotid gland infection as a source of meticillin-resistant Staphylococcus aureus bacteraemia has been rarely reported. It is predominantly a disease of the elderly and is associated with significant mortality. Two cases are described here that presented over a 6 month history at a district general hospital. Many cases may be preventable with adequate hydration and good oral hygiene, combined with effective infection control.

Diagnosis of major salivary gland tuberculosis: experience of eight cases and review of the literature

CONCLUSIONS

Tuberculosis of the salivary gland is mostly a medically curable disease entity but early diagnosis is very important to ensure complete remission. In cases with a high index of suspicion, reliable diagnostic methods such as polymerase chain reaction (PCR) should always be considered before surgical intervention to enable differential diagnosis of a salivary gland tumor.

OBJECTIVES

To investigate the clinical characteristics of major salivary gland tuberculosis and to review the literature relating to its diagnosis.

MATERIAL AND METHODS

Eight patients diagnosed as having major salivary gland tuberculosis between 1994 and 2004 were treated at one of three tertiary referral centers. Medical records, including imaging findings and the results of microbiological tests, Mycobacterium tuberculosis PCR and histopathology, were retrospectively retrieved and the literature was reviewed.

RESULTS

The parotid and submandibular glands were involved in 5 (62.5%) and 3 cases (37.5%), respectively. Neck CT demonstrated typical findings of salivary gland tuberculosis in 3 patients (37.5%). Fine-needle aspiration cytology revealed chronic inflammation in 6/7 patients (85.7%), 2 of whom (33.3%) showed caseous necrosis, strongly suggesting tuberculosis. Five of the 8 patients (62.5%) required resection of the affected gland and 3 (37.5%) received open biopsy. PCR was performed in half of the cases and was affirmative in every case. No significant differences were found between the surgically resected and non-resected groups in terms of treatment results or morbidity. All patients received anti-tuberculous chemotherapy for 8-12 months, with no disease recurrence.

Multiple suppurative cystic lesions of the lips and buccal mucosa: A case of suppurative stomatitis glandularis

Cheilitis glandularis (CG) is a rare inflammatory salivary gland disease that usually affects the lips. Although the etiology of CG is still unknown, it is believed to be a hereditary disease with an autosomal dominant pattern of inheritance. Three clinical presentations of CG are described in the literature: simple, superficial suppurative, and deep suppurative. A case of deep suppurative CG that extended to the buccal mucosa has been previously reported as suppurative stomatitis glandularis (SSG). Here we report a case of SSG in a 64-year-old white female with a history of bilateral renal transplants for adult polycystic kidney disease, who presented with painful swollen lips and bilateral buccal mucosal lesions. The diagnosis and management of the case is discussed. To the best of our knowledge, this is the second report of SSG, a rare condition affecting the minor salivary glands in the oral cavity.

What can transgenic and gene-targeted mouse models teach us about salivary gland physiology?

Thousands of genetically modified mice have been developed since the first reports of stable expression of recombinant DNA in this species nearly 20 years ago. This mammalian model system has revolutionized the study of whole-animal, organ, and cell physiology. Transgenic and gene-targeted mice have been widely used to characterize salivary-gland-specific expression and to identify genes associated with tumorigenesis. Moreover, several of these mouse lines have proved to be useful models of salivary gland disease related to impaired immunology, i.e., Sjögren's syndrome, and disease states associated with pathogens. Despite the availability of genetically modified mice, few investigators have taken advantage of this resource to better their understanding of salivary gland function as it relates to the production of saliva. In this article, we describe the methods used to generate transgenic and gene-targeted mice and provide an overview of the advantages of and potential difficulties with these models. Finally, using these mouse models, we discuss the advances made in our understanding of the salivary gland secretion process.

Oral tuberculosis: a clinical evaluation of 42 cases

OBJECTIVES

A retrospective review of a large series of oro-facial cases of tuberculosis to analyse clinical, histopathological, and radiological aspects, as well as those of chemotherapy.

MATERIALS AND METHODS

A total of 42 cases of tuberculosis of the oro-facial region were examined. Thirteen patients had a primary form and 29 a secondary form of the disease. Diagnosis was based on careful clinical examination, Mantoux reaction, histopathological examination, microbiological cultures and immunological investigation with the detection of antibodies against Mycobacteria in the patients' serum (ELISA).

RESULTS

Cases examined consisted of 27 males and 15 females. The age range was 3 to 73 years (mean age 31 years). Clinical manifestations comprised oral ulcers in 69.1%, bone involvement in 21.4%, and salivary gland and/or lymph node involvement in 14.3%. A total of 79.4% patients with secondary disease had pulmonary lesions, 15 of whom showed clinical and radiological signs of activity; there was one case of bilateral renal lesions and two of skin lesions.

CONCLUSIONS

Oro-facial tuberculosis is often difficult to diagnose and it should be an important consideration in the differential diagnosis of lesions that appear in the oral cavity. The most important diagnostic tools remain a careful clinical evaluation, biopsy for histologic study, as well as acid-fast stains, culture, and immunological assays, and skin testing.

Influence of outer surface protein A antibody on Borrelia burgdorferi within feeding ticks

Borrelia burgdorferi, the spirochetal agent of Lyme disease, is transmitted by Ixodes ticks. When an infected nymphal tick feeds on a host, the bacteria increase in number within the tick, after which they invade the tick's salivary glands and infect the host. Antibodies directed against outer surface protein A (OspA) of B. burgdorferi kill spirochetes within feeding ticks and block transmission to the host. In the studies presented here, passive antibody transfer experiments were carried out to determine the OspA antibody titer required to block transmission to the rodent host. OspA antibody levels were determined by using a competitive enzyme-linked immunosorbent assay that measured antibody binding to a protective epitope defined by monoclonal antibody C3.78. The C3.78 OspA antibody titer (>213 microgram/ml) required to eradicate spirochetes from feeding ticks was considerably higher than the titer (>6 microgram/ml) required to block transmission to the host. Although spirochetes were not eradicated from ticks at lower antibody levels, the antibodies reduced the number of spirochetes within the feeding ticks and interfered with the ability of spirochetes to induce ospC and invade the salivary glands of the vector. OspA antibodies may directly interfere with the ability of B. burgdorferi to invade the salivary glands of the vector; alternately, OspA antibodies may lower the density of spirochetes within feeding ticks below a critical threshold required for initiating events linked to transmission.

[Submaxillary sialolithiasis due to Actinomyces israelii. A case report]

Actynomicosis of the submaxillary gland is a very uncommon infectious disease. In this article one case of submaxillary sialolithiasis by actynomices israelii in a young girl is presented. We discuss several aspects of its diagnosis and therapeutic possibilities and review the literature on the subject. We emphasize the interest and value of performing a microbacteriological, mineralogical and pathological study of the calculi.

Absence of Helicobacter pylori DNA in salivary lymphoepithelial lesions

Helicobacter pylori is a common cause of chronic gastritis and has been implicated as the main agent responsible for the development of lymphomas of mucosa associated lymphoid tissue (MALT) in the stomach. An uncommon cause of salivary gland swelling is salivary lymphoepithelial lesion (SLEL), which shows histological features of acquired MALT and is associated with the development of MALT-type lymphomas. Since H. pylori has been identified in the oral cavity, we hypothesised that this organism might act as a potential antigen for the development of MALT in salivary glands. Routinely processed biopsies of 20 SLEL were screened for H. pylori DNA using a sensitive two-stage PCR technique to amplify the 16S ribosomal RNA gene. Immunoglobulin heavy chain gene monoclonality was determined by amplifying the VDJ gene using a nested PCR technique. All SLEL had histological features of organised MALT and 14 cases showed Ig heavy chain gene monoclonality consistent with MALT lymphoma. None of the SLEL contained H. pylori DNA. In contrast to the putative role of H. pylori as an antigenic stimulus in gastric MALT lymphomas, it appears not to play a role locally in the development of MALT or MALT lymphomas of the salivary gland.

Oral cryptococcosis: case report of salivary gland involvement in an AIDS patient

Salivary cryptococcosis was disclosed at autopsy in an AIDS patient with disseminated C. neoformans infection. H & E staining was not suitable to demonstrate the occurrence of C. neoformans in many tissues; Alcian blue gave the best results.

Potential of diagnostic microbiology for treatment and prognosis of dental caries and periodontal diseases

Most evidence suggests that only a finite number of bacteria are responsible for dental caries and periodontal diseases. This knowledge led to the development of microbial tests which can identify suspected pathogens. Current evaluation of the diagnostic power of microbial tests has shown that they have a low sensitivity and a low prognostic value. Despite these shortcomings, there are valid indications for microbiological-based diagnosis. Salivary microbial tests for the detection of mutans streptococci and lactobacilli may be useful, for example, in young children, oligosialic patients, and orthodontic patients. These tests can be used to monitor the success of chemopreventive measures or compliance with dietary recommendations. Microbial diagnosis, may also be valuable in the treatment of early-onset periodontitis or in subjects who respond poorly to periodontal therapy. The use of microbial tests to monitor the efficacy of chemotherapy or mechanical treatment is of particular interest.

Fine-needle aspiration biopsy of salivary gland mycoses

This report details the fine-needle aspiration biopsy (FNAB) cytomorphologic features of two cases of salivary gland mycosis. Both patients had acquired immunodeficiency syndrome (AIDS) and presented with parotid gland masses. The first patient had Histoplasmosis with secondary infection by Candida. Cytopathologically, the FNAB smears showed classic features of a deep-seated mycosis characterized by necrosis and scattered fungal forms. The second patient had a colonizing sialadenitis caused by either Asperigillus or Fusarium. Cytopathologically, the findings were similar to those seen in aspergillomas of the lung or paranasal sinuses with numerous hyphal forms and an absence of an inflammatory response. Because mycotic disease can induce a wide spectrum of pathogenic change, other benign or malignant, solid or cystic lesions enter into the differential diagnosis.

Human immunodeficiency virus type 1 replication within cystic lymphoepithelial lesion of the salivary gland

Cystic lymphoepithelial lesions of salivary glands (CLLSG) are nodular or diffuse salivary gland enlargements that are observed in patients who tested positive for human immunodeficiency virus type 1 (HIV-1). Two cases of CLLSG are reported. Particular emphasis is placed on the presence of HIV-1 major-core protein (P24), HIV-1 RNA sequences, Epstein-Barr virus (EBV) DNA sequences, and lymphocyte receptor gene rearrangement. Lymphoid alterations consisted of explosive hyperplasia with a prominent follicular reticular dendritic cell (DRC) network and numerous intrafollicular CD8+ lymphocytes. Intrafollicular DRC strongly expressed HIV-1 major-core protein and HIV-1 RNA, indicating that most DRCs actively replicated the HIV-1 virus. The presence of active HIV-1 replication within DRC and the absence of clonal EBV infected lymphoid population strongly suggest that CLLSG pathogenesis is primarily induced by HIV-1. The presence of oligoclonal immunoglobulin gene rearrangements in our cases, however, suggest the need of long-term follow-up of such patients to determine whether CLLSG could be a benign prelymphomatous disease.

Saliva and salivary gland alterations in HIV infection

HIV-1 infection may involve saliva and the salivary glands. The virus may be recovered from the mouth and anti-viral antibodies are found in saliva. Salivary dysfunction after infection ranges from xerostomia to a Sjogren's syndrome-like condition with persistent glandular enlargement and marked secretory hypofunction.

Experimental Parker's coronavirus infection in Wistar rats

Specific Pathogen Free (SPF) male Wistar rats were inoculated intranasally with Parker's rat coronavirus (PRC), then killed at various intervals post-inoculation (pi). PRC inoculated rats had transient respiratory signs. Intermandibular swelling was evident in some rats at 6-8 days pi. During the acute stages of the disease, inflammatory lesions were present in the respiratory tract and in the salivary and lacrimal glands. Regenerative lesions were observed in the salivary and lacrimal glands at 2 weeks pi. Inoculated rats seroconverted at 8-14 days pi, and significant coronaviral antibody titers were present in inoculated rats examined at 21 days pi with PRC. Changes in the respiratory tract and salivary and lacrimal glands were identical in incidence, distribution and nature to those observed in sialodacryoadenitis (SDA) virus inoculated Wistar rats. Thus, in the absence of viral isolation and characterization, "rat coronavirus infection" is a more appropriate term than either PRC infection or sialodacryoadenitis (SDA).

Duration of protection from reinfection following exposure to sialodacryoadenitis virus in Wistar rats

Wistar rats [Cr1:(WI)BR] were inoculated intranasally with approximately 10(3) median mouse lethal infective doses of sialodacryoadenitis (SDA) virus. Animals were subsequently selected at random, removed to a separate isolation room, and reinfected with SDA virus at 3, 6, 9, 12 or 15 months. Pre- and postinoculation serum samples were collected from all animals during the course of the study and evaluated for antibody titers to SDA virus. All experimental, control and sentinel animals, following inoculation with SDA virus, were necropsied and examined for lesions consistent with SDA. Salivary gland lesions were minimal to absent in rats reinfected with SDA virus for up to 12 to 15 months after the initial exposure and minimal to moderate in the respiratory tract at 12 or 15 months. SDA-associated lesions were extensive in age matched control animals examined at each time period of reinfection with SDA virus. Thus, prior exposure to SDA virus did protect against the development of typical salivary gland lesions for up to 15 months. Recovered animals were evaluated for their ability to transmit the virus following reinfection. Rats reinfected at 6 or 9 months were infectious to their naive cage mates. The results indicate that reinfection with homologous rat coronavirus can occur as early as 6 months after the initial infection, and such rats can transmit the infection to contact controls.

Head and neck manifestations of mycobacteria in the absence of pulmonary disease

Mycobacterial infections, once relatively rare in North America have recently shown an upsurge with the influx of Asian and African immigrants. The infections are usually due to M. tuberculosis and present with pulmonary symptoms. However, an uncommon presentation is that of a mass in the head and neck region without any pulmonary manifestations. Although these infections are usually secondary to invasion by "atypical" mycobacteria, unusual presentations due to mycobacterium tuberculosis have been noted. Case reports depicting the very rare presentations of M. tuberculosis in the thyroglossal duct cyst, parotid, and submandibular lymph node are described. A very unusual case of atypical mycobacteria in the larynx is noted and cervical adenitis is also included. The initial subtle presentation emphasizes the importance of mycobacteria in the differential diagnosis of lesions in the head and neck region.

[Cytomegalovirus isolation in chronic salivary gland diseases of adults]

The results of virological investigation of a rare clinical instance of familial disease with a localized form of cytomegalovirus infection which, as a rule, is not diagnosed in life are presented. The infection localized in the salivary glands was the source of generalization of the process with a high fever, eruptions, lymphadenopathy, inflammatory changes in the excretory ducts of the salivary glands. Exacerbation of the chronic process was accompanied with high antibody titres (1:256--1:1024) with inhibition of the cellular immunity reactions in the mother. The latent form of infection in the father and two daughters ran without clinical manifestations, with low antibody titres and moderate inhibition of cellular reactions. The isolated strains of cytomegalovirus were identical in all the subjects under study and antigenically close to the Ad-169 strain.

Suppuration of the submandibular salivary glands in the neonate

Suppurative sialadenitis is rare in the neonate and usually involves the parotid glands. Two cases are reported of suppuration of the submandibular gland in the newborn. Diagnosis was made by clinical signs of infection, appearance of a unilateral, erythematous submandibular mass, and expression of pus from the orifice of Wharton duct under the tip of the tongue. Gram stain, culture, and antibiotic sensitivity studies were done on the purulent material. Staphylococcus aureus grew in both cases and was sensitive to treatment with methicillin sodium. This report discusses the management of these cases, with speculation about the possible cause. To my knowledge, these are the only two cases found in the literature of suppurative submandibular sialadenitis occuring as an isolated lesion in the neonatal period.

Characterization of the virus of sialodacryoadenitis of rats: a member of the coronavirus group

The virus that causes sialodacryoadenitis in rats has been isolated in mice and in primary cultures of rat-kidney cells and has been characterized as a heat-labile RNA virus that is sensitive to lipid solvents and is relatively stable at pH 3.0. This virus is antigenically related to the virus of hepatitis in mice and to coronavirus of rats. The range of hosts of this agent appears to be narrow. On the basis of available biologic characteristics, it has been placed in the coronavirus group.

Extraneural rabies virus infection. Virus development in fox salivary gland

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