Paracoccus yeei: a Rare Opportunistic Bacterium in a Patient with Parotid Cyst.

BACKGROUND: Parotid cyst is a common problem in patients treated by surgeons. However, Paracoccus yeei was isolated from an aerobic blood culture in a patient with parotid cyst as an unusual etiologic opportunistic agent. METHODS: Since old biochemical identification kits are not able to identify this species, MALDI-TOF MS correctly was recommended to identify this isolate. Its identity was confirmed by sequencing of the 16S rRNA gene. RESULTS: The aligned sequences (16S rRNA gene) were used for a phylogenetic analysis (phylogenetic tree), which was produced using the BLAST pair-wise alignments. The sequence analysis determined that the best matches were with Paracoccus yeei. CONCLUSIONS: Paracoccus yeei has been reported as a rare opportunistic human pathogen, we should actively com-municate to the clinic to improve the real positive rate.

Non tuberculous mycobacterial lesion of the parotid gland and facial skin in a 4year old girl: A proposed treatment strategy.

OBJECTIVE: We report a case of a parotid-facial caseating granulomatous infection caused by atypical mycobacteria (Mycobacterium avium) in an immuno-competent child. The size and depth of the lesion and its proximity to the facial nerve present a challenge for a purely surgical treatment strategy. An alternative treatment strategy is developed to avoid severe disfigurement. STUDY DESIGN/SUBJECT: Atypical mycobacterial infection of the parotid region in a 5 year old girl: timeline and definition of a planned combined treatment strategy with antibiotics and surgical excision. RESULTS/CONCLUSION: Cervicofacial infections caused by non-tuberculous mycobacteria (NTM) may present surgical challenges due to the size and depth of the lesion and its proximity to the facial nerve and major vascular structures. Even minor scars are highly visible and poorly tolerated. Close clinical monitoring combined with judicious treatment strategies is necessary for successful treatment and good cosmesis. Recent literature provides insufficient guidance in formulating the best treatment strategy for the individual patient. Comparisons of antibiotic therapy with variations of surgical excision are abundant but poorly formulated. Our case presented with a lesion involving skin, superficial and deep lobe of the parotid gland. Lesion was in immediate proximity to the distribution of the facial nerve through the parotid gland. The risk of surgical damage to the facial nerve in the acute phase of the inflammation and the required extent of skin excision were significant. We decided to start treatment with combination antimycobacterial antibiotics in close cooperation with the pediatric infectious disease specialists. We observed and documented the regress and executed a delayed surgical excision when the lesion was reduced to skin only. In our opinion this was the best treatment strategy that helped us avoid extensive dissection in the vicinity of the facial nerve as well as a parotidectomy. Excision of the involved skin with the deep portion was performed 6.5 months after initial diagnosis.

Atypical mycobacteriosis involving parotid and para-retropharyngeal spaces.

The incidence of retro-parapharyngeal localization of cervical adenitis due to non-tuberculous mycobacteria is very rare. We present a case of an 18-months-old child with an involvement of parapharyngeal and retropharyngeal areas, right parotid and submandibular regions by atypical mycobacteriosis in the CT and MRI scan. The masses were surgically removed and the frozen-section histological exam upheld their atypical mycobacterial origin.

Bi-institutional analysis of microbiological spectrum and therapeutic management of parotid abscesses.

BACKGROUND: A parotid abscess (PA) is a complication of an acute bacterial parotitis with a potentially life-threatening course. To date, data on the diagnosis and therapy of PA is sparse and mostly consists of case reports or case series. Therefore, this study aimed at comprehensively analyzing the microbiological spectrum and the therapeutic management in a bi-institutional setting. METHODS: A retrospective clinical chart review was performed to identify all patients surgically treated for PA at two tertiary care centers in Germany. Data on demographics, clinical management and microbiological data including species identification, pathogenicity, type of antibiotic therapy, adjustment of antibiotics, antibiotic sensitivity testing, and smear test results were extracted. Intervention-related variables and etiology were analyzed for their statistical association with outcome variables. RESULTS: Overall, 85 patients were included. Most patients (92.9%) underwent surgical incision. Around half of the patients (45.9%) were treated under local anesthesia. No facial nerve palsy was observed. The most frequently detected pathogens were Streptococci (n = 23), followed by Staphylococcus aureus (n = 6) including one case of methicillin-resistant Staphylococcus aureus. Most patients (68.2%) received an aminopenicillin ± beta-lactamase inhibitor as empiric antibiotic therapy. In 6 cases the antibiotic therapy was modified after receiving the antibiogram. Four patients (5.2%) presented with recurrent PA. Etiology was idiopathic (42.4%), followed by tumorous (12.9%), obstructive, and immunosuppressive (each 11.8%). Patients with a dental focus (p = 0.007) had a longer duration of hospitalization. CONCLUSION: The results show that the surgical therapy of PA under local anesthesia is safe. A dental examination should routinely be performed to rule out a dental focus. Obtaining a microbiological specimen in order to modify antibiotic therapy if necessary and a histopathological specimen to rule out a tumorous etiology is obligate.

Parotid tuberculosis associated with cutaneous tuberculosis on a medial epicanthus.

An 83-year-old woman presented with a 2-month history of a gradually enlarging, reddish, crusted papule on her left medial epicanthus. Her medical history did not reveal any systemic disease. She gave no personal history of tuberculosis or any systemic symptoms, such as night sweat, weight loss, and pulmonary abnormalities. Her husband had been treated for pulmonary tuberculosis 30 years ago. A dermatologic examination revealed a 2.5 x 1.2-cm nontender, erythematous plaque with fine, white adherent scales on the left medial epicanthus (figure 1A). All laboratory values were within the normal range. Results from a tuberculin skin test were initially negative. A skin biopsy was performed, and a pathological examination demonstrated multiple noncaseating granulomas with various diameters in the reticular dermis and an infiltrate of neutrophils and lymphocytes in the surrounding dermis (figure 2). Periodic acid-Schiff, Ziehl-Nilsen, gram, and giemsa stains were negative for any microorganism. Leishman-Donovan-like bodies were observed within the epitheloid histiocytes that formed the granulomas. The pathological diagnosis was granulomatous dermatitis. The patient was diagnosed with cutaneous leishmaniasis (CL) based on her clinical appearance and histopathological findings, although the parasite was not detected in the tissue specimens. Treatment with intralesional glucantime for 5 consecutive weeks did not improve her condition. By the end of the fifth week, the patient developed asymptomatic facial swelling and a 1.5 x 1.2-cm erythematous plaque in the left parotid area (figure 1B). An ultrasonographic examination demonstrated a 13 x 11 x 17-mm hypoechoic mass, which suggested pleomorphic adenoma. In addition, lymph nodes, the largest of which were 9 x 10 mm, were noted in the left cervical area. A skin biopsy from the erythematous plaque of the left parotid area demonstrated diffuse neutrophilic infiltration with formation of focal granulomas. Tuberculosis was suspected, and mycobacterium tuberculosis (MT) was isolated from the culture. A tuberculin skin test was performed again, which was positive (12 mm). The erythrocyte sedimentation rate was 35 mm/h, and all other laboratory tests were within normal limits. Pulmonary radiography and thoracic computerized tomography findings were normal. Fine needle aspiration biopsy and ultrasonographic examination of the parotid mass were performed, which revealed necrotic material with neutrophils and lymphocytes (figure 3). We treated the patient with a standard antituberculous regimen, comprising isoniazid 300 mg/d, rifampin 600 mg/d, ethambutol 1200 mg/d, and pyrazinamide 1500 mg/d. By the end of the second month of treatment, the patient improved considerably. There was a marked reduction in facial swelling, and the lesion on the left medial epicanthus regressed dramatically (Figure 4A and Figure 4B). No adverse effects of the medication occurred. An additional 7 months of therapy with isoniazid and rifampin was planned.

Parotid actinomycosis mimicking metastatic lymphadenopathy.

We present a patient with actinomycosis of the parotid, as confirmed by histology, and discuss the challenges involved when clinical and radiological findings are highly indicative of metastatic malignancy. Early treatment with antibiotics is indicated infungating or infected masses and exclusion of malignancy by histology is often needed.

Candidal abscess of the parotid gland due to Candida glabrata: report of a case and literature review.

We report the case of an immunocompetent woman who developed a Candida glabrata abscess of the parotid gland and present a review of similar cases from the literature. Diagnosis was based on the isolation of C. glabrata in pure culture from the abscess pus. Examination of stained smears of the same material demonstrated small sized yeast cells, some being intra-macrophagic. Combination of a local drainage and oral fluconazole proved to be an efficient therapeutic strategy. Candidal abscesses are rare in immunocompetent patients and salivary gland localization has only been reported in five cases.

Isolation and characterization of Bartonella quintana from the parotid gland of an immunocompetent man.

We describe a case of the isolation of Bartonella quintana from the parotid gland of an apparently healthy man. Pathological examination showed intraparotid granulomatous abscessual lymphadenitis. Diagnosis was made on the basis of high titers of immunoglobulin G (IgG) and IgM antibodies and of culture isolation of a causative agent from parotid aspirate.

Tuberculosis of the parotid gland.

Tuberculosis (Tbc) presented as an isolated parotid mass is rare. Preoperative diagnosis is difficult and the symptomatology is nonspecific. In the majority of the cases an initial diagnosis of a parotid tumor, often a pleomorphic adenoma, is made. We present a 35-year old woman with a six months duration right parotid lump. The mass was firm and nontender without ipsilateral cervical lymphadenopathy, suggesting a parotid neoplasm. The computerized tomography scan showed an intraparotideal tumor resembling a pleomorphic adenoma and thus the patient underwent to a superficial parotidectomy. Fine needle aspiration biopsy was performed but it was not diagnostic. Histological examination revealed an intraparotideal lymph node with changes of granulomatous lymphadenopathy type, like those demonstrated in the tuberculosis and sarcoidosis. Ziehl-Nielsen staining was negative, while the tuberculin skin test (PPD, 5 IU) was positive. The patient's treatment regimen consisted of a 2-month initial phase of isoniazid, rifampin, pyrazinamide and ethambutol followed by a 7 month continuation phase of isoniazid and rifampin. Postoperatively, there was only a mild paresis of the facial nerve resolved a week after. Parotid Tbc is very rare but should be considered as a differential diagnosis of parotid lumps. Fine needle aspiration biopsy (FNAB) is of outmost importance for diagnosis, since the treatment of this entity is primarily conservative. However, surgery could be both therapeutic and diagnostic, especially when other diagnostic examinations fail.

Histological surprise of parotid tuberculosis: about two cases.

Parotid tuberculosis remains a very rare localization in the Department of Otolaryngology and Cervico-Facial Surgery (ENT) sphere. It is presented in the form of a deceptive clinical picture causing confusion with other pathologies of the parotid gland, including tumor pathology. In addition, its lack of knowledge by practitioners increases the risk of missing the diagnosis. Often, the diagnosis is a histological surprise on a piece of excision after an exploratory parotidectomy. However, its treatment is primarily medical if the positive diagnosis is well established. We report medical observation of two new cases aged 44 and 45 respectively, who consult our center for parotid swelling. Radiological examinations were in favor of intraparotid cystic lesions. Both patients benefited from an excision whose histopathological study was in favor of primary parotid tuberculosis. The subsequent evolution was favorable under antituberculous treatment.

Gas-forming parotid abscess in a diabetic patient: an unusual complication of Salmonella enteritidis bacteremia.

Parotid abscess, not only a focal infection but also a sequela of systemic infection, necessitates the detailed search for the underlying pathogens. A 76-year-old diabetic male visited the emergency room of a hospital because of intermittently low-grade fever and a painful lump in the right parotid gland region for 7 days. Progressive painful swelling of the gland with the signs of severe sepsis developed 3 days later. Computed tomography of the neck revealed a cavitary lesion with an air-fluid level in the right parotid space. Superficial parotidectomy was performed. Salmonella enteritidis was isolated from both the pus and the blood culture. After a 2-week course of intravenous ampicillin and an additional 2-week course of oral moxifloxacin, he was free from recurrence at a 6-month follow-up. This case highlights that an initially nontoxic parotitis may be the presenting feature of extraintestinal salmonellosis. Early diagnosis and treatment are important to prevent lethal dissemination in high-risk groups.

[Tuberculosis of the parotid gland]. / Tuberkulose in der Glandula parotidea.

The different tumours of the parotid gland can be divided in benign or malignant tumours, regional inflammations and enlarged lymph nodes. We report on a 26-year-old male from Uganda with a slowly growing tumour of the right parotid gland for several months. The CT scan showed a poorly defined intraparotideal tumour. Ultrasonography revealed multiple enlarged cervical lymph nodes. Suspecting a neoplasm of the parotid gland we decided to perform a superficial parotidectomy for histological examination. The pathological analysis revealed a caseous necrosis and epitheloid granulomata containing Langhans giant cells. The polymerase chain reaction could not confirm our suspicion of tuberculosis. The Ziehl-Neelsen staining did not show any acid-proof rods. Only the breeding of the suspicious probes generated Mycobacterium tuberculosis. Initially denying any infections the patient admitted to having had tuberculosis that had been treated with antibiotics 2 years previously. Tuberculosis is a rare finding in parotid tumours. It must be considered as a differential diagnosis of parotid enlargements.

Cases presenting as parotid abscesses in children.

BACKGROUND: A parotid abscess is a rare complication of acute suppurative parotitis which most often requires hospitalization, intravenous antibiotic therapy, and surgical drainage. OBJECTIVE: To investigate the clinical picture, treatment, and prognosis of children with a parotid abscess in a search for optional clinical guidelines for treatment. METHODS: A retrospective chart review was performed for 10 children (age

Parotid tuberculosis.

Parotid gland tuberculosis is an uncommon manifestation of one of the most common infections even in the developing countries, caused by Mycobacterium tuberculosis. There are no specific symptoms or clinical signs of parotid tuberculosis, and such an infection most commonly presents as a slow growing painless parotid mass. Because of its rarity, tuberculosis of parotid gland is often mistaken for a malignant growth, and it most commonly gets diagnosed after superficial protidectomy. Complete cure is possible with standard antituberculous therapy. Most of our knowledge about this rare entity comes from case reports and short case series. The authors encountered three cases of parotid tuberculosis in the last 10 years. This article aims at presenting a comprehensive review of all the available literature and thus providing detailed information and an update on parotid tuberculosis and our experience of three cases.

Anti-interferon-γ autoantibody-associated disseminated Mycobacterium abscessus infection mimicking parotid cancer with multiple metastases: A case report.

RATIONALE: Among the nontuberculous mycobacteria, Mycobacterium abscessus is a common cause of skin, soft tissue, and bone infections. However, disseminated M. abscessus infection that mimics cancer metastasis with an underlying relatively immunocompetent condition has rarely been reported. PATIENT CONCERNS: A nonsmoking 73-year-old man with an underlying relatively immunocompetent condition reported a 2-month history of a mass in the region of his right parotid gland that had been steadily increasing in size. DIAGNOSES: The head and neck computed tomography showed an avidly enhancing tumor with central necrosis in the right parotid region and lymphadenopathy bilaterally at neck levels II-V (<6 cm) with a necrotic core. The radiologist and otolaryngologist both suspected a diagnosis of right parotid gland cancer with metastasis. INTERVENTIONS: The necrotic tissue was removed surgically, and Mycobacterium culture showed M. abscessus. We collected a blood sample and detected anti-interferon-γ autoantibody. OUTCOMES: After 6 months of anti-M. abscessus treatment, physical examination showed remission of the parotid tumor, and axillary and supraclavicular lymphadenopathy. LESSONS: We report a case of disseminated M. abscessus infection, which involved parotid glands with multiple lymphadenopathies in a person with an underlying relatively immunocompetent condition. Possible underlying mechanisms such as anti-interferon-γ autoantibody-associated immunodeficiency should be considered in a patient with disseminated M. abscessus infection without a known immunocompromised condition.

Alkanindiges hongkongensis sp. nov. A novel Alkanindiges species isolated from a patient with parotid abscess.

A bacterium was isolated from the abscess pus of a 72-year-old patient with Warthin's tumor and parotid abscess. The cells were aerobic, non-motile, Gram-negative but difficult to be destained, non-sporulating, coccobacillus. The bacterium grew poorly on sheep blood agar and MacConkey agar as non-hemolytic colonies of 0.5 mm in diameter after 24h of incubation at 37 degrees C in ambient air. Growth was enhanced by Tween 80. It produces catalase but not cytochrome oxidase. Sequencing of the cloned 16S rRNA PCR products of the bacterium revealed three different 16S rRNA gene sequences, with 12 - 31 bp differences among them. Phylogenetic analysis showed that the bacterium is closely related to Alkanindiges illinoisensis, with 5.0 - 5.9% differences between the 16S rRNA gene sequence of the bacterium and that of A. illinoisensis. Tryptophan auxotrophic strain of Acinetobacter trpE27 transformed with DNA extracted from the bacterium was unable to grow on tryptophan deficient medium, indicating that the bacterium was not a strain of Acinetobacter. The G+C content of the bacterium (mean +/-SD) was 46.9+4.3%. A new species, Alkanindiges hongkongensis sp. nov., is proposed, for which HKU9T is the type strain. Isolates with "small colonies" that are apparently Acinetobacter-like species should be carefully identified. Growth enhancement with aliphatic hydrocarbons should be looked for and 16S rRNA gene sequencing performed in order to find more potential cases of Alkanindiges infections, as well as to define the epidemiology, clinical spectrum, and outcome of infections associated with this genus.