11-year-old girl with facial swelling and fever
An 11-year-old girl was admitted to the hospital for evaluation of left-sided facial swelling with subjective fever. The history of the chief complaint revealed that this episode began about 1½ weeks ago with painless swelling. Five days before admission, she was noted to be febrile and was taken to her primary provider for evaluation who treated her with Augmentin and prednisone. Two days later, she went to the ER due to increasing pain, where she had a CT scan that revealed cervical lymphadenopathy and the enlarged left parotid with possible abscess formation (figure 1). Her antibiotic was changed from Augmentin to clindamycin. On the day of admission, she was seen in the ENT clinic, where the otolaryngologist felt she was worsening and needed IV antibiotics.
Vice Chair for Education at The Children’s Hospital at Scott
and White and Associate Professor of Pediatrics at Texas A&M University,
College of Medicine, Temple, Texas. E-mail: firstname.lastname@example.org.
Her past medical history is positive for having had three previous, less severe episodes over the last 18 months. Otherwise, she is a healthy child with no other significant medical or surgical problems. Her immunizations are up to date and she has no known allergies. Her family history is equally unremarkable.
Examination revealed normal vital signs and a normal-appearing 11-year-old girl with marked, painful swelling of the left side of her face in front of the ear (figures 2 & 3). Her ears, eyes and oral exam were normal. Specifically, there was no exudate from Stensen duct and her eyes and other mucous membranes were well hydrated. The rest of her examination was also normal.
Lab tests included only a normal CBC.
What’s Your Diagnosis?
- Acute suppurative parotitis
- Juvenile recurrent parotitis
- Sjögren’s syndrome
This is a case of juvenile recurrent parotitis, an uncommon inflammatory condition of the parotid, the cause of which is unknown. It may be related to the small caliber of the ducts in affected children. Available data seem to indicate that its peak occurrence is in the toddler’s age group and again in the pre-adolescents. The episodes can last one to two weeks and can have several episodes per year. Painful swelling is the most common complaint. About half will also have fever. Occasionally, it may be misdiagnosed as cervical lymphadenopathy, but it is usually easy to distinguish a swollen parotid by the location; in front of the ear, just above the angle of the mandible. Imaging can also be done with CT or MRI, which will reveal parotid swelling, sometimes with cystic lesions as was the case here as shown in figure 1. Imaging also helps rule out a stone in the gland.
While antibiotics are frequently used, they are thought to be of no benefit in the majority of cases. However, it appears that in some cases, secondary bacterial infections occur, as they appear to rapidly improve on antimicrobials. The patient presented was treated with clindamycin plus ceftriaxone with what appeared to be a good response, and she went home on oral clindamycin. Sialagogues (tart candy-like lemon drops or similar items) can augment therapy by stimulating salivation. In difficult cases, recent data support the use of sialendoscopy with lavage and steroid injection.
We should always discourage any surgical approach to the problem, as the risk of facial nerve damage is significant, and the problem virtually always spontaneously resolves by adolescence, probably with growth.
Some associated diseases that should be considered include Sjögren’s syndrome and immunodeficiency, including HIV, which may present with acute or chronic parotitis. This patient had no other clinical evidence of Sjögren’s syndrome (dry eyes and mouth), and her immune workup was normal. Sjögren’s syndrome is an autoimmune disorder that affects the exocrine glands and may also have features of juvenile rheumatoid arthritis. This patient had none of these findings.
Acute suppurative parotitis will present with a more acute onset of painful swelling and fever. The appearance of the patient may not be much different (figures 4 & 5), except for the more rapid onset and a bit more erythema. There may be pus discharging from Stensen duct. The cause is usually Staphylococcus aureus, but it can be mixed with anaerobes and occasionally coliforms. If pus can be expressed, a culture should be obtained and antibiotics against these organisms should be started pending culture results.
Mumps, and its complications such as encephalitis and orchitis, are caused by the mumps virus and is fairly rare in this country with the widespread use of the MMR vaccine. It is characterized by a febrile illness with bilateral swelling of the parotid glands (figure 6, courtesy of Andy Margilith, MD, figure 7). Treatment is supportive. Other viruses that can cause parotitis include enteroviruses (Coxsackievirus), EBV, influenza, parainfluenza, HIV, as noted above, and probably many others. To read more about Mumps, please see Larry Pickering’s excellent review of the disease on the front page of the April issue of AAP News.
As we move into the summer months, we will soon, if not already, start seeing enteroviral diseases and all their wide array of manifestations; from aseptic meningitis to neonatal hepatitis, from flu-like illnesses to hand-foot-mouth disease. As noted above, sometimes acute parotitis may also be due to enteroviruses, especially coxsackievirus. However, as bad as you may think enteroviral diseases are, and they are at times very bad, if you are about my age, or older, you probably recall when a trio of enteroviruses terrified entire communities. Of course, I refer to polioviruses. Because I spent my early years in a city where four outbreaks of poliomyelitis occurred between 1937 and 1955 (Fort Worth, Texas), my mother was quick to have my older brother and I enroll along with about 35,000 other Texas children to receive the investigational Salk vaccine in the spring of 1954. I was 7 years old and remember it like yesterday. I remember the exam room, and where my brother sat as my mother encouraged me to hold still for Dr. Taylor to administer the first of three injections over a five-week period. Some refer to these children as Polio Pioneers, and I would like to think that I would have volunteered, but after that first injection, I would probably have not returned for the other two. Fortunately, my mother was making the decisions. My only pleasure was to get up on the table first to receive mine so I could enjoy watching my older brother squirm during those moments between seeing the doctor prepare the needle and syringe and actually being stuck, knowing I already had it behind me. I know it’s wrong, but I really enjoyed that.
This, of course, is a child’s recollection. The terrifying effect this disease had on our parents, I’m only now coming to understand as I read about these years in a new book, The Polio Years In Texas, Battling a Terrifying Unknown, by medical historian, Heather Green Wooten, PhD (figure 8). While the book focuses on polio in Texas, Dr. Wooten reviews at some length the national movement against this crippling disease and the influence of President Franklin Roosevelt on funding the research leading to the development of the first vaccine.
Now, polio is essentially eliminated from the Western Hemisphere, Western Pacific Region and Europe. The book also documents numerous heartbreaking personal accounts of those unfortunate souls for whom the vaccine came too late. One of the polio survivors interviewed for the book recalled seeing her father take all her belongings to a barrel in the alley behind their house to burn them, including her favorite dresses and toys, thinking of these things as a possible cause for her disease. She remembered him falling apart, “his heart broken and sitting on the ground, all alone in the alley, he cried his heart out” (page 74). I strongly recommend Heather Wooten’s book for anyone with an interest in the history of polio, and what physicians and nurses went through taking care of these children, and be glad we don’t have to round on children in Iron Lungs anymore.