Tuberculosis of the Parotid gland

Posted: Tuesday, November 16, 2010 | Posted by Debajyoti Datta | Labels: ,

Recently I came across a case report on tuberculosis of the parotid gland by Garg et al. published in Lung India. Although rare, parotid tuberculosis should be considered in the differential diagnosis of parotid swelling that is slowly progressive. The diagnosis of parotid tuberculosis requires a high degree of clinical suspicion to avoid unnecessary surgery.

Parotid tuberculosis: Features
Parotid gland is the largest salivary gland in the body, draining in the oral cavity via Stenson’s duct opposite the upper second molar tooth. The swelling in case of parotid tuberculosis is a slowly progressive one, toothache and trismus may also be present.
Discharging sinuses may also be present over the swelling in case of parotid tuberculosis. There may be associated enlargement of the lymph nodes of the neck. Facial nerve involvement should also be noted. Fever may also be present. History of tuberculosis should also be worked out.
Infection of the parotid gland by M. tuberculosis causing parotid tuberculosis may occur directly through the oral cavity or it may be a blood borne infection from distant foci or via the lymphatics from the oral cavity.

Investigations
Hemoglobin levels may be decreased. This may be due to the chronic infection or it may be due to malnutrition. There may be predominance of lymphocytes in the blood.

Imaging: High resolution ultrasonography of the parotid region is the initial investigation of choice. This is important as it provides an index of suspicion. In another case report by Kundu et al. preoperative diagnosis of parotid tuberculosis was not done as this investigation was not performed. The diagnosis as made on subsequent histopathological examination of the excised lesion. Ultrasonographically, parotid tuberculosis can be divided in to parenchymal type and periparotid type.
Chest X-ray should also be done to look for any pulmonary lesions.

Tests for Tuberculosis
  • Mantoux test – it is not diagnostic.
  • Sputum for presence for acid fast bacilli.
  • ELISA for anti tubercular IgM and IgG.
  • FNAC with Ziehl-Neelsen staining for acid fast bacilli.
  • Histopathological examination.

Treatment
Multidrug therapy for 6 months with 4 drugs (Isoniazid, Rifampicin, Pyrazinamide, Ethambutol) in the intensive phase and 2 drugs (Isoniazid, Rifampicin) in the continuation is the treatment of choice.
The authors also state that 3 (Isoniazid, Rifampicin, Pyrazinamide) drugs in the intensive phase and 2 drugs in the continuation phase may also be adequate as this is a paucibacillary form.

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3 comments:

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