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Pediatrics International (2013) 55, 6064 doi: 10.1111/j.1442-200X.2012.03738.x

Original Article

Neonatal suppurative parotitis over the last 4 decades: Report of three


new cases and review

Essam A Ismail, Tarek M Seoudi, Mohamad Al-Amir and Ahmad A Al-Esnawy


Paediatric Department, Farwaniya Hospital, Kuwait

Abstract Background: Neonatal suppurative parotitis is a rare disease. Only 32 cases were reported in the English-language
literature between 1970 and 2004.
Methods: We searched Medline for acute, neonatal, bacterial, suppurative, parotitis, facial, preauricular swelling
starting from 1970, limiting our search to the English-language literature. We reviewed all the reported cases together
with three more managed in our department.
Results: We identified nine new cases since 2004. The total number of patients reviewed was 44, including our patients.
Most of them were male (77%). The majority developed unilateral inflamed parotid swelling (77%) and exuded pus from
the ipsilateral Stensen duct. Fever was seen in fewer than half of them (47%). Premature babies constituted a third of the
patients. Staphylococcus aureus was the leading causative agent (61%). Most patients responded well to conservative
treatment with antibiotics (77%). The most frequently used combination of antibiotics was an anti-staphylococcal agent
with either an aminoglycoside or a third-generation cephalosporin. A minority required surgical drainage. No deaths
were reported in the group studied after 1970.
Conclusion: Neonatal suppurative parotitis is rare but easy to diagnose and if readily treated with appropriate antibiotics
the outcome is excellent.

Key words bacterial, neonatal, parotitis, preauricular, suppurative.

Neonatal suppurative parotitis (NSP) is rare; fewer than 90 cases Spiegel et al.2 and the nine reported since 2004 (totaling 44
were reported before 1970.1 cases).
Spiegel et al.2 reviewed 32 cases of NSP reported in the
English-language literature between 1970 and 2004. Most of Case reports
them appeared as single case reports. NSP commonly presented
Case 1
with irritability, swelling, erythema and tenderness over the
affected parotid gland in the presence or absence of fever. Pus A 9-day-old breast-fed boy presented with a 1-day history of
exuding from the Stensen duct or aspirated from the affected fever, irritability, poor sucking and left pre-auricular swelling. He
gland was considered pathognomonic. Staphylococcus aureus was born at term by cesarean section after an uneventful preg-
was the most frequent offending organism, but other Gram- nancy. Birthweight was 3850 g. On admission the baby was irri-
positive, Gram-negative and anaerobic organisms were also iso- table and looked unwell. His weight was 4300 g, and rectal
lated.2 It is thought that they get access to the gland by either temperature was 39.2C. Examination revealed a swelling and
ascending through the Stensen duct or, less commonly, by the redness over the left parotid gland. Pus exuded from the left
hematogenous route. Stensen duct when pressure was applied to the gland. The rest of
Most cases were treated only with antibiotics, but few patients the physical examination was unremarkable.
needed surgical drainage. Laboratory tests revealed a hemoglobin of 15.9 g/dL; white
We reviewed the English-language literature from 2004 to blood cell (WBC) count 20 500/mm3, 72.5% were neutrophils;
identify any additional cases of NSP. We found only nine new erythrocyte sedimentation rate (ESR) 19 mm/h; and serum
reports, each describing a single case.311 amylase concentration 35 U/L (normal range, 25125 U/L).
We describe three more cases managed in our department over Serum electrolytes were as follows: urea 9 mg/dL; sodium
the last year and review them together with those studied by 136 mmol/L; potassium 4.8 mmol/L; and chloride 103 mmol/L.
The parents declined lumbar puncture. Ultrasound examination
of the parotid glands demonstrated enlarged left parotid gland
Correspondence: Essam A Ismail, MRCP (UK), Paediatric Depart- with diffuse hypoechogenicity of the parenchyma, compatible
ment, Farwaniya Hospital, PO Box 936, Salmiya 22010, Kuwait.
Email: rsessam@hotmail.com with parotitis (Fig. 1). Computed tomography (CT) scan con-
Received 22 April 2012; revised 4 September 2012; accepted 5 firmed the same findings. Treatment with i.v. fluid, cloxacillin
September 2012. 200 mg/kg/day and cefotaxime 200 mg/kg/day (each divided

2012 The Authors


Pediatrics International 2012 Japan Pediatric Society
Neonatal parotitis 61

ebrospinal fluid cultures were sterile. The antibiotic treatment


was changed to i.v. vancomycin (40 mg/kg/day) and gentamicin
(5 mg/kg/day). The left parotid abscess was surgically drained on
the next day and the patient showed gradual improvement. The
treatment was continued for 14 days with complete recovery. The
patient did not show on follow up.
Case 3
A 16-day-old breast-fed girl was admitted because of left parotid
gland inflammation 2 days before admission. She was born at
37 weeks by normal vaginal delivery and her birthweight was
3250 g. On examination she appeared irritable and dehydrated
and her weight was 2900 g. Her temperature was 37.2C. Pus
exuded from the left Stensen duct opening. Systemic examina-
tion was otherwise unremarkable. Total WBC count was 28.1
103/mm3. The hemoglobin, serum C-reactive protein, and ESR
levels were 15.5 g/dL, 6.2 mg/dL, and 2 mm/hr, respectively.
Serum urea was 5 mg/dL; sodium 139 mmol/L; potassium 4.5
mmol/L; and chloride 109 mmol/L.
Fig. 1 Ultrasound color Doppler picture showing the enlarged left
Ultrasound findings were similar to Case 1. She was started on
parotid gland of case 1 and displaying hypoechoic edematous texture
with congestion (arrow). i.v. fluids for rehydration, vancomycin (40 mg/kg per day) and
gentamicin (5 mg/kg per day in two divided doses). Culture of
the purulent exudates from left Stensen duct and blood revealed
6-hourly) was started. The parotid pus, nasal swab and urine S. aureus while the urine and cerebrospinal fluid were sterile. The
cultures, but not the blood, grew methicillin-resistant S. aureus parotid swelling disappeared within 3 days but the antibiotic
(MRSA) on the third day after admission. Despite clinical therapy was continued for 14 days. The patient did very well on
improvement and based on culture, the antibiotic treatment was follow up after 3 months.
switched to vancomycin 40 mg/kg/day, divided every 6 h, for 10
more days. The patient was discharged well but did not appear on Discussion
follow up. The three patients reported here are similar to those reported
before. All neonates showed parotid gland swelling with varying
Case 2
An 11-day-old bottle-fed boy presented with 8 days history of
right pre-auricular swelling followed 2 days later by swelling on
the left side. Pregnancy and delivery at term were uneventful.
Birthweight was 2200 g and there were no perinatal problems.
On admission, the baby was irritable but not in a critical
condition and clinically well-hydrated. His weight was 2320 g
and rectal temperature was 38.5C. Both parotid glands showed
signs of inflammation. Pus exuded from the Stensen duct of the
right gland on the fourth day of admission. The remainder of the
physical examination was unremarkable. Laboratory results were
as follows: hemoglobin 15.2 g/dL; WBC count 8.7 103/mm3;
C-reactive protein 23.4 mg/L (reference range is less than 8);
serum amylase concentration 5 U/L; urea 4.5 mg/dL; sodium
144 mmol/L; potassium 5.6 mmol/L; and chloride 110 mmol/L.
Ultrasound examination demonstrated enlarged superficial and
deep parts of both parotid glands, displaying hypoechoic texture
with massive edema. Few pockets of thick pus were noted
(Fig. 2). CT scan of the parotid glands confirmed the same
findings.
Intravenous cloxacillin (100 mg/kg/day) and cefotaxime
(100 mg/kg/day) were commenced. The fever resolved within 6 h
after admission but the local signs of inflammation did not Fig. 2 Ultrasound picture of case 2 demonstrating the enlarged
improve. The right Stensen duct pus yielded growth of right parotid gland with pockets of thick turbid fluid (arrow) display-
methicillin-resistant S. aureus (MRSA), but the urine and cer- ing posterior acoustic enhancement.

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Pediatrics International 2012 Japan Pediatric Society
62 EA Ismail et al.

Table 1 Clinical features of patients with neonatal suppurative parotitis

Ref. No. of patients Gestation preterm Sex male Unilateral parotid swelling Fever present Surgical drainage
2 32 11 23 26 12 7
3 NR 3 NR
311 9 2 9 6 5 2
1 NR
Current report 3 0 2 2 2 1
Total number (%) 44 13 34 34 19 10
(%) 100% 32% 77% 77% 47% 23%
NR, not reported.

degrees of erythema, warmth and tenderness. Parotid gland choice of antibiotic guided by the local antibiotic policy and the
involvement was unilateral in 77% of cases (Table 1). All had pus sensitivity pattern of local organisms.
exuding from the Stensen duct when pressure was applied exter- Other less frequently encountered bacteria included Gram-
nally to the affected gland or aspirated from it, except in two positive cocci constituting about 25% of isolates. Gram-negative
cases.6,9 In these two patients, the parotid glands showed all signs bacilli constituted about 16% of isolates especially from patients
of inflammation and the ultrasound examination of both was with septicemia who had nosocomial infection.1,2,11 Anaerobic
consistent with parotitis. Blood cultures isolated Streptococcus bacteria were a minority (11%) (Table 2). Two organisms were
pyogenes in the first case and Group B Streptococci in the second, recovered simultaneously from the Stensen duct discharge from
so they were included in the study.6,9 In two other patients, the each of six patients.1,12,1517
exuded pus did not grow any organism12,13 but the blood culture Blood cultures were positive in 11 of 31 patients studied
isolated Staphylococcus epidermidis in one of them.13 (35%). The same organism was isolated from the Stensen duct
Male patients outnumbered female patients (77% were male). discharge in all patients except three.6,9,13 There was no discharge
The majority of patients were in fair general condition on pres- from two.6,9
entation except when the organism was isolated from the The causative agents are thought to be derived from the
blood.1,4,9 Notably, fever was not a universal feature and was patients mouth flora. The newborns acquire their first microflora
reported in fewer than half of the patients (47%). of the mouth, ear and skin from the mothers birth canal during
The peripheral WBC count was reported to be more than 15 normal vaginal delivery.18
109/L in 71% of patients in a previous study2 and 69% when the Parotid gland infection may take place by one of two routes.
newly studied patients were added. But only 44% of the patients Either ascending through the Stensen duct, and this appears to be
had elevated WBC if the cut-off count was taken as more than the most common way, or by hematogenous spread as part of
20 109/L. septicemia.1,4,6,9
Laboratory investigations are generally not very helpful in the Ascending infection is thought to be facilitated by dehydra-
diagnosis of NSP and in fact are not necessary in a typical case. tion thereby reducing salivary flow.2 The cause of dehydration
Serum amylase was high in four out of 16 patients (25%) for was not clear in the majority of patients.1
whom the test was done, including our patients.2,3,6,7,9,11 About 78% (11 of 14) of the patients with NSP for whom the
S. aureus was the most frequently isolated pathogen (61%). type of feeding was reported were breast-fed.2,49,11,14,19 This is
MRSA was isolated in two of our three patients and was reported much higher than the 44% breast-feeding initiation rate in the
in one other study.14 This should be considered in the initial general population.20 This raises the possibility that insufficient

Table 2 Bacteria cultured from patients with neonatal suppurative parotitis

Ref. No. of Blood culture growth Culture of pus from the affected parotid gland
patients (number of patients) (number of patients)
2 32 SA (4), PsA (1), SA (18), SV (4), SP (2), COS (2), SC (1), E. coli (2), KP (2),
E. coli (1), COS (1) PsA (1), MC (1), Ba (2), Pr (2), PSC (1).
311 9 SA (1), GBS (1), SP (1) SA (6), PsA (1), No discharge (2)
Current report 3 SA (1) MRSA (2), MSSA (1)
Overall 44 11/31 SA: 27 patients (61%)
(%) 35% GP: 11 patients (25%)
GN: 7 patients (16%)
Anaerobic organisms: 5 patients (11%)

Total number of patients reported. Ba, Bacteroides; COS, Coagulase negative staphylococci; E. coli, Escherichia coli; GBS, group B
Streptococci; GN, Gram-negative bacilli; GP, Gram-positive cocci, including blood isolates, other than Staphylococcus aureus; KP, Klebsiella
pneumoniae; MC, Moraxella catarrhalis; MRSA, methicillin-resistant SA; MSSA, methicillin-sensitive SA; Pr, Prevotella; PsA, Pseudomonas
aeruginosa; PSC, Peptostreptococcus; SA, Staphylococcus aureus; SC, Streptococci (unspecified); SP, Streptococcus pyogenes; SV, Streptococcus
viridans.

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Pediatrics International 2012 Japan Pediatric Society
Neonatal parotitis 63

breast-feeding could, at least in part or in some patients, be from the affected gland is pathognomonic; however, when there
responsible for some degree of dehydration in these neonates. is no discharge from the Stensen duct, then bacterial growth from
Insufficient breast-feeding has been shown to be frequently the blood culture in this context is highly suggestive of the
missed but increasingly recognized.21 Unfortunately, relevant diagnosis. The most common causative agent is S. aureus, but
data were not available in the vast majority of previously reported other Gram-positive, Gram-negative and anaerobic bacteria are
cases to draw any conclusion. This needs to be looked at in future isolated less frequently. Most patients can be treated conserva-
studies. tively, provided that the empiric antibiotic treatment covers the
Other risk factors implicated were environmental hot causative agents according to the local sensitivity pattern and is
weather,4 excessive oral suctioning and nasogastric tube- started early. The prognosis of the disease is generally excellent.
feeding.13,22 In more recent reports, NSP was linked to maternal
breast abscess in a breast-fed infant4 and in another to cytome- Acknowledgment
galovirus parotitis and maternal treatment with methyldopa.3,5 We are indebted to Professor Allie Moosa, visiting consultant
Prematurity was reported in almost one-third of cases (32%) pediatrician Al-Adan Hospital, Kuwait for the critical review of
of NSP. This contrasts with the average worldwide prematurity the manuscript and Dr Ahmad Hassan, from the X-ray Depart-
rate of 9.6%.23 Prematurity, therefore is a risk factor. ment, Farwaniya Hospital for providing us with the ultrasound
Hematogenous spread was seen less frequently as part of images.
septicemia either associated with early pneumonia, congenital
malformations,1,13 multiple skin abscesses14,24 or as part of late- Disclosure
onset neonatal sepsis.6
The authors declare that they have no conflict of interest.
Ultrasound findings were rather consistent, commonly reveal-
ing enlarged glands with edema, increased vascularity and hyp- References
oechoic areas. Some reports demonstrated intraparotid lymph
node enlargement.6,811,19 1 Leake D, Leake R. Neonatal suppurative parotitis. Pediatrics 1970;
46: 2038.
There is rarely any difficulty in making the diagnosis but the 2 Spiegel R, Miron D, Sakran W, Horovitz Y. Acute neonatal sup-
differential diagnosis may include mandibular osteomyeli- purative parotitis: case reports and review. Pediatr. Infect. Dis. J.
tis, acute suppurative lymphadenitis, infected hemangioma or 2004; 23: 768.
lymphangioma. 3 Todoroki Y, Tsukahara H, Kawatani M et al. Neonatal suppurative
The majority of patients were treated successfully with a parotitis possibly associated with congenital cytomegalovirus
infection and maternal methyldopa administration. Pediatr. Int.
combination of antibiotics that included an antistaphylococcal 2006; 48: 1856.
agent and an aminoglycoside or a third-generation cephalosporin. 4 Singh K. Bilateral parotid abscess in a neonate. Indian Pediatr.
Based on the spectrum of bacteria causing NSP (Table 2), we 2006; 43: 100910.
would advocate the same combination of antibiotics empirically 5 Mohyud-Din M, Haider S, Hameed A. Bilateral suppurative paro-
pending the result of culture and sensitivity. Awareness of the titis in a newborn. J. Coll. Physicians Surg. Pak. 2006; 16: 3012.
6 Walter C, Noguera A, Gene A, Jimenez R, Fortuny C. Group B
local sensitivity pattern of the microbial organisms is an impor- streptococcal late-onset disease presenting with parotitis. J. Pae-
tant asset in the successful management of such small babies. In diatr. Child Health 2009; 45: 7646.
responsive patients the fever usually settles down within 24 h and 7 Akgun C, Peker E, Akbayram S, Dogan M, Tuncer O, Kirimi E. A
the swelling within 35 days of starting the antibiotic treatment. 3-day-old boy with a right preauricular swelling. Euro J Pediatr.
The ideal duration of antibiotic treatment is not known, but the 2010; 169: 6378.
8 Khan SU, OSullivan PG, McKiernan J. Acute suppurative neona-
shortest effective duration reported in treating NSP due to S. tal parotitis: case report. Ear Nose Throat J. 2010; 89: 901.
aureus and in the absence of septicemia was 7 days3,5 and the 9 Herrera Guerra AA, Osguthorpe RJ. Acute neonatal parotitis
longest was 21 days with anaerobic organisms.17 Variables like caused by streptococcus pyogenes: a case report. Clin. Pediatr.
prematurity, septicemia, other organ involvement and type of (Phila) 2010; 49: 499501.
organism might need to be considered in deciding the duration of 10 Miranda A, Pereira KD. Neonatal suppurative parotitis. Ear Nose
Throat J. 2010; 89: 4889.
treatment. Only 23% needed surgical drainage. This included 11 zdemir H, Karbuz A, Cifti E, Fitz S, Ince E, Dogru U. Acute
patients who came late to medical attention (more than 45 days neonatal suppurative parotitis: a case report and review of the
from disease onset)4,17 or the organism was resistant to the literature. Int. J. Infect. Dis. 2011; 15: 5002.
empiric antibiotic therapy.5,17 12 Chiu CH, Lin TY. Clinical and microbiological analysis of six
The prognosis seems to be excellent in terms of morbidity and children with acute suppurative parotitis. Acta Paediatr. 1996; 85:
1068.
mortality. Historically, complications included salivary fistula, 13 Chevalier J, Jadcherla SR. Parotid swelling in a premature neonate.
facial palsy, mediastinitis, septicemia and meningitis.1 There are Am. J. Perinatol. 2002; 19: 4357.
no reported deaths after the early study of Leake and Leake in 14 Managoli S, Chaturvedi P. Suppurative parotitis in a neonate.
1970.1 Also, no serious complications were reported. Indian Pediatr. 2002; 39: 4078.
In conclusion, NSP is a rare disease that presents classically, 15 David RB, OConnell EJ. Suppurative parotitis in children. Am. J.
Dis. Child. 1970; 119: 3325.
in the majority of patients, with unilateral parotid swelling and 16 Sabatino G, Verrotti A, de Martino M, Fusilli P, Palllotta R,
variable degrees of local signs of inflammation. Purulent dis- Chiarelli F. Neonatal suppurative parotitis: a study of five cases.
charge exuding from the ipsilateral Stensen duct or aspirated Eur. J. Pediatr. 1999; 158: 3124.

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Pediatrics International 2012 Japan Pediatric Society
64 EA Ismail et al.

17 Brook I. Suppurative parotitis caused by anaerobic bacteria in 22 Fathalla B, Collins D, Ezhuthachan S. Acute suppurative parotitis:
newborns. Pediatr. Infect. Dis. J. 2002; 21: 812. uncommon presentation in a premature infant. J. Perinatol. 2000;
18 Ross JM, Needham JR. Genital flora during pregnancy and colo- 1: 579.
nization of the newborn. J. R. Soc. Med. 1980; 73: 10510. 23 Beck S, Wojdyla D, Say L et al. The worldwide incidence of
19 Schwab J, Baroody F. Neonatal suppurative parotitis: a case report. preterm birth: a systematic review of maternal mortality and mor-
Clin. Pediatr. 2003; 42: 5656. bidity. Bull. World Health Organ. 2010; 88: 318.
20 Arora S, McJunkin C, Wehrer J, Kuhn P. Major factors influencing 24 Salaria M, Poddar B, Parmar V. Neonatal parotitis. Indian J.
breastfeeding rates: mothers perception of fathers attitude and Pediatr. 2001; 68: 283.
milk supply. Pediatr 2000; 106: e67.
21 Moritz ML, Manole MD, Bogen DL, Ayus JC. Breastfeeding-
associated hypernatremia: are we missing the diagnosis? Pediatr
2005; 116: e343e347. doi: 10.1542/peds.2004-2647.

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