Medical Journal of Dr. D.Y. Patil Vidyapeeth

CASE REPORT
Year
: 2014  |  Volume : 7  |  Issue : 1  |  Page : 56--58

Tuberculosis of parotid gland masquerading as Pleomorphic adenoma


Vadisha Bhat, Biniyam Kolathingal, Rajeshwary Aroor, Madhukar Muniswamy Gowda 
 Department of Otorhinolaryngology, K S Hegde Medical Academy, Mangalore, Karnataka, India

Correspondence Address:
Vadisha Bhat
Department of Otorhinolaryngology, K S Hegde Medical Academy, Mangalore - 575 018, Karnataka
India

Abstract

Salivary gland is one of the rare sites of tuberculosis, even though extrapulmonary tuberculosis accounts for 15-20% of all cases of tuberculosis. When it involves parotid gland, the presentation is usually with a slow growing swelling, which makes one to think of a neoplasm. The treatment of tuberculosis is medical, with antituberculosis treatment. However occasionally, the diagnosis of tuberculosis is done following a surgery performed for a suspected parotid tumor. Here we report a case of tuberculosis of parotid gland in a lady who underwent superficial parotidectomy for a parotid mass.



How to cite this article:
Bhat V, Kolathingal B, Aroor R, Gowda MM. Tuberculosis of parotid gland masquerading as Pleomorphic adenoma.Med J DY Patil Univ 2014;7:56-58


How to cite this URL:
Bhat V, Kolathingal B, Aroor R, Gowda MM. Tuberculosis of parotid gland masquerading as Pleomorphic adenoma. Med J DY Patil Univ [serial online] 2014 [cited 2022 Jul 5 ];7:56-58
Available from: https://www.mjdrdypu.org/text.asp?2014/7/1/56/122778


Full Text

 Introduction



Though tuberculosis is a common disease especially in the developing countries, and about 15-20% of tuberculosis are extrapulmonary, tuberculosis affecting the parotid gland is rare. [1] Less than 200 cases of parotid gland tuberculosis have been reported in the literature. The clinical presentation is either as acute parotitis, an abscess resistant to common antibacterial agents, a fistula or by a slowly growing mass within the gland, indistinguishable by a neoplasm. [1],[2] Majority of the cases are diagnosed with ultrasonography and Fine needle aspiration cytology. However, few patients underwent parotidectomy for a suspected neoplasm and histopathological examination showed tuberculosis. [2],[3],[4] Here we report a case of a female patient presented with a parotid swelling, diagnosed clinically as neoplasm, underwent superficial parotidectomy, and the histopathological diagnosis was tuberculosis. The disease responded well to antituberculosis medication.

 Case Report



A 45-year-old female patient presented to the department of ENT with a history of a slowly progressive swelling in the right parotid region since two years. There was history of occasional pain. There was no history of fever. No other swellings were noticed elsewhere in the body. The swelling was subjected to Fine needle aspiration cytology twice in the past, and the reports were benign mucinous cyst on one occasion features of pleomorphic adenoma on the other.

Ultrasonography of the parotid showed a 2.1 × 7.3 cm hypoechoic lesion in the right parotid gland. Keeping the diagnosis of pleomorphic adenoma in mind, superficial parotidectomy was planned under general anesthesia GA. A 2 × 3 cm cystic lesion was noticed in superficial lobe. All the branches and main trunk of facial nerve was indentified and preserved. Postoperative period was uneventful. Histopathology examination (HPE) microscopy revealed areas of fibrosis with aggregates of lymphocytes. Focal areas showed granulomas comprising of epithelial cells and plenty of Langhan's cells. Langhan's cells were of both giant cell type and foreign body giant cells. The resected lymph nodes in the parotid gland showed reactive hyperplasia. A histopathological diagnosis of tuberculous granuloma was arrived at [Figure 1]. Further investigation of the chest X-ray and sputum Acid fast bacillus staining (AFB) did not yield any evidence of pulmonary tuberculosis. The patient was started on antituberculosis treatment under DOTS category 1. The patient tolerated the treatment well. On follow-up, the patient was asymptomatic during one year post treatment period.{Figure 1}

 Discussion



Tuberculosis is a chronic granulomatous inflammation caused by mycobacterium tuberculosis with varied clinical presentation. It's a common infection in the developing countries; the incidence is more following the emergence of HIV infection. It mainly affects the lung, while 15-20% of cases are extrapulmonary- affecting the lymph nodes, bones, kidney and meninges. [1],[2] Tuberculous lymphadenopathy is the main form of extrapulmonary tuberculosis, affecting mainly the cervical lymph nodes. [2] Involvement of salivary glands by tuberculosis is a rare entity, even in countries where tuberculosis is rampant. Less than two hundred cases of parotid gland tuberculosis are reported in the literature. The rarity of tuberculosis in salivary glands could be because of the inhibitory effect of saliva on mycobacteria. Saliva has a bactericidal effect due to the presence of thiocyanate ions and lysozymes. Also, the constant flow of saliva prevents the inoculation of mycobacteria within the gland parenchyma. [5] Among the salivary glands, parotid gland is the most commonly affected, comprising of 70% of all salivary gland tuberculosis. [6] Suoglu et al., in their review of 216 parotidectomies, found tuberculosis in 2.8% cases. [7] Tuberculosis is primarily confined to the intraglandular and periglandular lymph nodes and invasion of parenchyma is usually secondary to spread from these lymph nodes. There are various postulates regarding the source of tuberculosis infection in parotid. Van Stubenrauch in one of the earliest reports of tuberculosis of salivary glands, postulated that extension of infection along Stenson's duct from the oropharynx is the main mode of infection. [8] Bockhorn proposed a hematogenous spread from any primary focus in the body. [9] According to Berman and Fein, infection reach the parotids via lymphatics, particularly from infected tonsils. [10]

Most of the reported cases in the literature are females. [5] The commonest mode of presentation of tuberculosis of parotid gland is a slowly growing painless mass. In this situation, it mimicks a neoplasm, and a high index of suspicion is required for the diagnosis. [2] Some cases of tuberculosis of parotid gland may present with an abscess which is resistant to antibacterial therapy. [11] The abscess tend to recur on repeated aspiration. Tuberculosis can also present as acute parotitis, or occasionally with a fistula. [1],[2] Rarely, facial palsy may be the presenting feature of tubercular parotitis. [5] Tuberculosis is reported to be common in diabetics owing to the impaired cellular immunity in people with poorly controlled diabetes. However this is more so in cases of pulmonary tuberculosis than extrapulmonary. [12] Human innumodeficiency virus HIV is another risk factor of increased susceptibility to tuberculosis. [13]

Imaging and Fine Needle Aspiration Cytology (FNAC) are useful in diagnosis of parotid gland tuberculosis. [14] Ultrasound guided FNAC has the advantage of taking the sample from a more representative area, to minimize the false results in blind aspiration. However, multiple passes may be required to get adequate samples for cytological study and AFB staining of the aspirated material, and the final diagnosis is made based on these results. Cytological studies when combined with stains for AFB achieve better results. Cultures of mycobacterium are complementary to these, however yield rate is not high. [15] Polymerase chain reaction is a more sensitive and specific method by which tuberculosis can be confirmed. [16] When ultrasonography and FNAC are inconclusive, parotidectomy is performed. Histopathological features of tuberculosis are caseating granulomas of tuberculosis. Staining by an acid fast method may show acid fast bacilli. Chest radiographs and sputum examination for acid fast bacillus need to be performed, for categorizing the patient for treatment. The treatment of tuberculosis of parotid gland is with antituberculosis medication if the diagnosis is done clinically, radiologically and with the aid of FNAC. However, even if the diagnosis is made in a parotidectomy specimen, a complete course of antituberculosis medication needs to be given once the diagnosis is established. Follow-up of the patients is needed to assess the response and to recognize the adverse effects of the antituberculosis medications.

 Conclusion



Tuberculosis of the parotid gland is a rare entity. However, this should be one of the differential diagnoses in a patient with parotid swelling when the sonological and cytological findings are not characteristic of a neoplasm. High index of suspicion, early diagnosis and timely institution of antituberculosis treatment if essential for establishing cure.

 Acknowledgements



The authors are thankful to Dr Satheesh Kumar Bhandary, Dean of our institution and Dr Jayaprakash Shetty, Professor and Head of the Department of Pathology, Staff of Departments of pathology and Radiodiagnosis for their valuable help and suggestions.

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