A 77-year-old man was admitted to the internal medicine department for a 5-day history of progressive preauricular swelling. The swelling was painless, insidious in onset and progressively increased in size. The patient had been previously evaluated by his primary doctor on 2 occasions and was on oral ciprofloxacin without any improvement. The patient reported that he felt weaker than usual over the past 7 days. No history of fever, cough, shortness of breath or weight loss was noted.
His past medical history was relevant for end-stage chronic renal disease secondary to diabetic nephropathy, hypertension, coronary artery disease and chronic obstructive pulmonary disease. His family history was relevant for type 2 diabetes mellitus and hypertension.
With respect to social history, he had no known drug or food allergies, as well as no history of smoking, alcohol abuse or illicit drug use. There had been no exposure to tuberculosis and no recent travels.
The physical examination revealed an alert patient with a regular pulse rate of 84 beats/min, blood pressure of 110/70 mmHg, a respiratory rate of 20 breaths/min and an oxygen saturation of 95% while breathing room air. Local examination revealed a 4x3 cm swelling in the left parotid region that was slightly tender accompanied by small non-painful anterior cervical lymphadenopathies. Heart sounds were regular without any rubs or murmurs. The lungs were clear. The rest of the physical examination was normal.
Blood tests showed elevated C-reactive protein (330 mg/l), leucocytosis (17.59x109/l) with a predominance of polynuclear neutrophils (13.72x109/l) and thrombocytosis (555x109/l). The glomerular filtration rate (GFR) was 15 ml/min, serum creatinine was 357 mumol/l and urea was 31.8 mmol/l. Electrolytes were within normal ranges. Coagulation, liver and thyroid tests were normal. Angiotensin-converting enzyme, antinuclear antibodies and anti-SSA/SSB were negative. Serology for HIV, HBV, HCV, CMV and EBV returned negative. Blood cultures were negative.
Ciprofloxacin was discontinued and intravenous ceftriaxone 1,000 mg and metronidazole 500 mg 3 times per day was initiated. On day 5 after admission, no clinical or biological improvement was achieved. A non-contrast neck scan was performed; it showed the presence of a significant infiltration of the left parotid compartment with parotitis without any detected collection. The infiltration extended to the left latero-cervical part of the compartment up to the base of the neck with fat infiltration, thickening of the skin and thickening of the superficial cervical fascia (Fig. 1).
After discussion, fine needle aspiration cytology (FNAC) was conducted. The cytological assessment showed only neutrophils, lymphocytes and cellular debris. Smear staining with the Ziehl-Neelsen stain as well as a PCR test were positive for Mycobacterium tuberculosis. These results were confirmed with culture of the sample. The patient was diagnosed with tuberculous parotitis and anti-tuberculous drugs were initiated. Chest radiography was normal and the Tuberculosis Skin Test (PPD) was 12 mm.