89

American Journal of
Experimental and Clinical Research
Am J Exp Clin Res 2015;2(1):89-90

Case Report
Acute suppurative parotitis: A rare entity in early infancy

Hosein Heydari1, Bahareh Abtahi-Naeini2, Mohsen Akhavan Sepahi1, Ali Saffaei3, Mohsen Pourazizi4*
1
Pediatric Medicine Research Center, Qom University of Medical Sciences, Qom, Iran
2
Department of Dermatology, Skin Diseases and Leishmaniasis Research Center, Students’ Research Committee, Isfahan
University of Medical Sciences, Isfahan, Iran
3
Pharmacy Students’ Research Committee, School of Pharmacy, Isfahan University of Medical sciences, Isfahan, Iran
4
Students’ Research Committee, Semnan University of Medical Sciences, Semnan, Iran.

Abstract. Acute suppurative parotitis (ASP) is a rare entity in early Infancy. The clinical presentation may be non-specific. Here, we
describe a 70-day-old breast-fed female infant with massive purulent drainage from the mouth. Diagnostic workup such as ultrasound
revealed purulent exudate from Stensen’s duct consistent with parotitis. Culture of the exudate showed growth of Staphylococcus Aureus.
Based on the clinical presentations and ultrasound findings, the patient was diagnosed with right ASP. The patient responded well to a 7-
day antibiotic therapy and supportive measures. Thus ASP should be considered in the differential diagnosis of a neonatal parotid swelling
and purulent drainage from the mouth, since early and prompt diagnosis prevents morbidity and complications. To the best of our
knowledge it is the first documented case of ASP in early infancy in Iran.

Keywords: Parotitis, Infant, Infection

Introduction day of admission, she presented with purulent drainage

Acute suppurative parotitis (ASP) is rarely encountered from the mouth associated with low grade fever and
in the neonatal and early infancy age group [1-3]. The irritability. Her weight was 4600 g and axillary
peak incidence of this disease is between the age of 2 and temperature was 38.5 degree centigrade.
14 [4]. Due to the rarity of acute suppurative parotitis, it is The parents reported no history of trauma to the infant's
important to gain exact and extensive insight into the face or head, and the mother denied any history suggestive
general and specific aspects of the pathological changes of of mastitis or recent skin infection. General examination
salivary glands, in these age groups for prompt diagnosis revealed an irritable, non-toxic looking, febrile infant. She
to prevent complications. Here, we describe a female was in a state of normal hydration and perfusion.
infant with acute suppurative parotitis, due to the rarity and The anterior fontanelle was normotensive and the
unusual presenting signs i.e. massive purulent drainage occipito-frontal circumference was 38.5 centimetre.
from the mouth. A study by Spiegal et al identified only 32 Examination of the head and neck revealed a diffuse,
cases over four decades in the English literatures, and tender, firm 3.0×3.0 centimetre area of induration with
found a 72% male prevalence [2]. However, to the best of mild enlargement of the right mandibular and right
our knowledge it is the first documented case in Iran. The preauricular region (the zone of the parotid gland) (Fig. 1).
clinical characteristics and treatment options of this rare The overlying skin was mildly inflamed with no obvious
infection are also reviewed. erythema or warmness. Pus exuded from the right inflamed
Stenson's duct especially when pressure was applied to the
Case Report gland. The rest of the physical examination was
A 70-day-old breast-fed female infant presented with a unremarkable. Parotid pus, blood, and urine cultures were
1-day history of fever and purulent drainage from the obtained.
mouth. She was born at 38 weeks gestation via natural Initial laboratory tests showed a hemoglobin level of
vaginal delivery with a birth weight of 2960 grams. 9.7 g/dl and total white blood cell count of 15200 /mm3
Perinatal history was unremarkable. with 57% neutrophils, 40% lymphocytes. Blood culture for
Her postnatal course was further complicated by the bacterial growth was egative. The erythrocyte sedimen-
development of neonatal poor feeding and sepsis. On the tation rate was 77 mm/h and C-reactive protein, 54/3 mg/dl.
The renal and liver function tests, serum electrolytes, and
___________________________________________________________
* Corresponding author: Mohsen Pourazizi, MD
([email protected]).
Am J Exp Clin Res, Vol. 2, No. 1, 2015 http://www.ajecr.org
 90

infection is more common from oral flora tracking in a

retrograde fashion into the gland [5]. Although, several
risk factors for the development of ASP have been
identified, but our patient did not show any such risk
factors.
These risk factors include: low birth weight, oral
trauma, immune suppression, and congenital variations in
the ductal structure. Sepsis and malnutrition are also
frequently observed in infants with parotitis. Dehydration
is another risk factor as it causes salivary stasis leading to
bacterial ascent from the oral cavity [7, 5]. Breastfeeding
or contaminated formula can transmit bacteria and
potentially cause sialadenitis [8]. In our case, the infant
Figure 1 Mild enlargement of the right mandibular and right was breastfed but her mother did not show any signs of
preauricular region (arrow). mastitis as it is reported by Sekhon et al [9].
The differential diagnosis of facial swelling that may be
urine analysis were normal. Direct smear from Stensen's confused with parotid enlargement includes: maxillary
duct showed gram positive Cocci with 6-8 white blood infections, trauma, lymphangiomas, hemangiomas,
cells and the culture showed growth of Staphylococcus lipomas, adenomas, extrapulmonary manifestations of
Aureus. In sensitivity studies, the organism was sensitive tuberculosis and the human immunodeficiency virus in
to vancomycin, cephalexin, novobiocin, ceftriaxone, cipro- susceptible populations [5, 10].
floxacin, cefazolin andtrimethoprim/sulfamethoxazole. In conclusion, although ASP is rare, it should be
Ultra-sonography of the parotid glands revealed an strongly considered in cases of neonatal and infantile
enlarged right parotid gland with heterogeneous sepsis associated with facial swelling with or without any
echogenicity compatible with ASP, without any abscess predisposing factors, as septic parotitis could be easily
formation. Cervical and intraparotid lymph nodes were missed without careful examination.
normal. Based on the clinical presentations and ultrasound
findings, the patient was diagnosed with acute right ASP. Conflict of Interest
She was treated with a 7-day course of parenteral The authors declare no conflicts of interest.
clindamycin at 10 mg/kg/doses every 6 hours and amikacin
at 15mg/kg/day. After 3 days of parenteral antibiotics References
therapy, the fever resolved and on the 5th day of treatment 1. Leake D, Leake R. Neonatal suppurative parotitis.
the parotid swelling gradually resolved. Follow-up Pediatrics 46:202-207, 1970.
examination demonstrated no residues or abnormalities of 2. Spiegel R, Miron D, Sakran W, Horovitz Y. Acute
the gland and she did not show chronic recurrent parotitis. neonatal suppurative parotitis: case reports and review. Ped
Infect Dis J 23:76-78, 2004.
Discussion 3. Ellies M, Laskawi R. Diseases of the salivary glands
The most common presentation of ASP is fever, in infants and adolescents. Head Face Med 6:1, 2010.
swelling and erythema in the pre-auricular area [5]. 4. G. Seifert AM, Haubrich J, Chilla R. Virus-
Purulent drainage from Stenson's duct is pathognomonic of sialadenitis. In: Speicheldrüsenerkrankungen, Pathologie,
this condition, and culture of the exudate will both confirm Klinik, Therapie, Fazialischirurgie. Thieme, Stuttgart, NY,
the diagnosis and is of great help in the treatment [5]. The S.131-136, 1984.
diagnostic criteria of suppurative parotitis include: a 5. Schwab J, Baroody F. Neonatal suppurative parotitis:
combination of parotid swelling, purulent exudation from a case report. Clin Ped 42:565-566, 2003.
Stenson's duct, and growth of pathogenic bacteria in the 6. David RB, O'Connel EJ. Suppurative parotitis in
pus culture [6, 2]. children. Am J Dis Child 119:332-335, 1970.
Our patient fulfilled all these criteria. Although the 7. D’Souza JN, Geary C, Mukerji S. Neonatal parotid
diagnosis of ASP is primarily based on the patient’s gland enlargement: Is it suppurative parotitis? A case
clinical findings, but examination with ultrasound as a non- report. Am J Case Reports 13:41, 2012.
invasive and useful option may help confirm the diagnosis 8. Ozdemir H, Karbuz A, Ciftci E, Fitoz S, Ince E,
(as was applied in our patient), differential diagnosis to Dogru U. Acute neonatal suppurative parotitis: a case
exclude other predisposing factors such as the anatomical report and review of the literature. International journal of
abnormalities of Stenson's duct, mechanical salivary duct infectious diseases. Int J Infect Dis 15:e500-502, 2011.
obstruction secondary to sialolithiasis, and infection related 9. Sekhon P, Williams D, Sara JDS, McCulloch NA.
to parotid gland, and neoplasms are also of great Acute bacterial suppurative parotitis of the neonate: A case
importance [5]. report and review. Int J Ped Otorhinolaryngol 7:132-133,
Advanced imaging studies may be considered when the 2012.
diagnosis is in doubt to rule out other congenital and 10. Stiller M, Golder W, Doring E, Biedermann T.
inflammatory disorders of the parotid gland [5]. Bacterial Primary and secondary Sjogren's syndrome in children- a
seeding of the parotid can occur hematogenously, but comparative study. Clin Oral Invst 4:176-182, 2000.

Am J Exp Clin Res, Vol. 2, No. 1, 2015 http://www.ajecr.org