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Neonatal Suppurative Parotitis Over The Last 4 Decades PDF
Neonatal Suppurative Parotitis Over The Last 4 Decades PDF
Original Article
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.
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
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
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.
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
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