DOI: 10.5958/j.2319-5886.2.2.

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International Journal of Medical Research & Health Sciences

www.ijmrhs.com
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Volume 2 Issue 2 April-June

Coden: IJMRHS
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Copyright @2013

ISSN: 2319-5886

Received: 28 Feb 2013 Case report

Revised: 22 Mar 2013

Accepted: 24th Mar 2013

TUBERCULOUS PAROTID LYMPHADENITIS IN A HIV POSITIVE PATIENT: A CASE REPORT * Garkal Shailendra M1, More Sumeet S1, Jadhavar Avinash L1, Tewari Suresh C2 Senior Resident, 2 Professor and HOD, Department of Medicine, Pravara Rural Hospital & Medical College, Loni, Ahmednagar, Maharashtra, India.
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*Corresponding author email: drshailendragarkal@gmail.com

ABSTRACT

Tuberculosis is a chronic, granulomatous disease. Primary lesion usually occurs in the lung. Extra pulmonary infection commonly involves head, neck and the abdomen. In an attempt to highlight an uncommon presentation, we document a case of extra pulmonary tuberculosis in the parotid gland (tuberculous parotitis), without evidence of pulmonary tuberculosis. A 15 year old HIV positive female patient was reported with chief complaint of repeated history of loose stools, vomiting, and swelling in the left parotid region and difficulty in opening of the mouth. She was diagnosed to be having tuberculosis of parotid gland after Ultrasonography (USG), fine needle aspiration cytology (FNAC), histopathological examination and was treated medically. Keywords: HIV, Tuberculosis, Tuberculous Parotitis.
INTRODUCTION

Tuberculosis is a chronic, granulomatous disease commonly affecting the lungs. It is one of the leading infectious diseases in the world. India accounts for nearly one third of the global burden of tuberculosis.1 One third of the 42 million people living with HIV/ AIDS worldwide are coinfected with tuberculosis. Approximately about two million HIV infected persons living in India are coinfected with tuberculosis. Tuberculosis is one of the main causes of death in HIV positive patients involving multiple organs, particularly the lungs. Tubercular involvement of parotid gland is extremely

unusual even in countries with high incidence of this infection such as India. Less than 200 cases have been reported since the first description of this condition by Von Stubenrauch in 1894.2
CASE

A 15 yrs old female, patient reported with the chief complaint of repeated history of loose stools and vomiting since 1 month and swelling in the left parotid region and difficulty in opening of mouth since 15 days. Medical history revealed that patient was diagnosed as HIV positive one year ago and she was on antiretroviral therapy.
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Physical examination revealed a soft to firm nonmobile, nontender swelling which was 33 cm in diameter. It was extending from pinna to the outer canthus of the eye and down upto the lower border of the mandible. There was no facial nerve involvement and cervical lymphadenopathy. Intraoral examination did not reveal any significant findings. Her routine haematological and biochemical investigations showed raised ESR and WBC count. X-ray chest was normal. USG parotid revealed multiple heterogeneous moderately enhancing soft tissue density lesions in superficial as well as deep lobe of parotid gland on left side suggestive of intra parotid lymph nodes.

FNAC of left parotid showed moderately cellular smears comprised of inflammatory cells mainly lymphocytes, macrophages and some epitheloid cells. Background showed hemorrhage and necrosis. Suggestive of granulomatous inflammation. A final diagnosis of tuberculosis of parotid gland in a HIV positive patient was made. Patient was referred to DOT centre where she was started on antitubercular drugs under CAT- I. For the initial 2 months she was put on, Isoniazid, Rifampicine, Ethambutol and Pyrazinamide on alternate days. One month after initiation of therapy parotid swelling was reduced.

Fig 1 : Anterior view of patient showing left parotid enlargement

Fig 2: Anterior view showing reduced swelling after antitubercular therapy

Fig 3,4 :Ultrasonography of parotid gland showing multiple intra parenchymal lymph node

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Fig 5: Fine needle aspiration cytology showing Granulomatous lesion with epitheloid cells and lymphocytes. DISCUSSION

Extrapulmonary forms of tuberculosis account for approximately 20% of overall active tuberculosis, but the salivary glands appear to be rarely affected. This may be due to the inhibitory effect of saliva on mycobacteria.3 Tuberculosis of the parotid gland is uncommon and less than 200 cases have been reported since the first description of this condition by Von Stubenrauch in 1994. Tuberculous parotitis occurs in 2.5% 10% of parotid gland lesion even in countries where the disease is endemic such as India.3 Tuberculosis of parotid glands may be clinically misdiagnosed as parotitis, Warthins tumours, mixed tumours and sometimes malignant tumours. Histo-pathologically there are two types of Granulomatous parotitis: (i) localised disease with a solid mass corresponding to tuberculosis in the lymph node of the parotid, (ii) diffuse disease involving parenchyma with nodules of irregular size and consistency.3 The pathogenesis of parotid tuberculosis remains unclear. Involvement of the parotid gland and lymph nodes may occur in two ways: (i) a focus of mycobacterial infection in the oral cavity liberates the mycobacterium which ascends into the salivary gland via its duct or passes to its associated lymph nodes via lymphatic vessels.4,5 (ii) second pathway involves hematogenous or

lymphatic spread from a distant primary lung focus.3,5,6 Tuberculous intraparotid lymphadenopathy has been described by Ubbi et al among others.7 similar finding was observed in our case. HIV infection is considered as the most prominent risk factor in acquiring active tuberculosis and tuberculosis involving the parotid gland.8 Diagnosis was invariably established on the basis of histopathological examination. In parotid lesions FNAC has a sensitivity of 81- 100% and specificity of 94-100%.
REFERENCES

1. Park K: Tuberculosis: epidemiology of communicable diseases. In: Parks Text Book of Preventive and social medicine, 18th Edn.; Banarsidas Bhahot Publishers Jabalpur, 2005;pp:146 -47. 2. Von Stubenrauch L. Einen Uberfall von tuberculoser Parotitis. Arch Klin Chir. 1894;47:2632. 3. Birkent H, Karahatay S, Akcam T, Durmaz A, Ongoru O: Primary parotid Tuberculosis mimicking parotid Neoplasm: A case report. Journal of Medical Case Reports, 2008; 2:6263

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4. Frank J. Primary tuberculosis of the parotid gland. Ann Surg 1902;36:945-50. 5. Lee IK, Liu JW. Tuberculous parotitis: case report and literature review. Ann Otol Rhinol Laryngol 2005;114:547-51. 6. Hamdan AL, Hadi U, Shabb N. Tuberculous Parotitis: a forgotten entity Otolaryngology Head Neck Surg. 2002; 126:581-82 7. Ubbi SS, Neoptolemos JP, Walkin DFL. Incidence and diagnosis of parotid gland Tuberculosis in Asians in Leicester. Br. J.Surg. 1988;75:313. 8. Rinaggio J: Tuberculosis. Dental clinics of North America, 2003; 47(3):449-65.

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