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Old 06-26-2011
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Question Right-sided facial pain!

A 71-year-old man presents to the emergency room complaining of severe right-sided face pain that has become pregressively worse over the past several days. He says that he is homeless and has not had anything to eat since the pain started as chewing makes it worse. He appears unkempt and has poor oral hygiene. The right side of his face appears swollen and erythematous. His temperature is 102.8°F (39.4°C). His white blood cell (WBC) count is 28,000 with a left shift. Based on these findings which diagnosis is the most likely?

Answer Choices
A. Acute parotitis
B. Closed fracture of the right zygoma
C. Mumps
D. Salivary gland tumor
E. Sjögren’s syndrome
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Old 06-26-2011
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Default A. acute parotitis

I would go with parotitis!

Probably related to poor hygiene.
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Old 06-27-2011
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Option A (Acute parotitis) is correct. The combination of poor oral hygiene and lack of oral intake predisposes to bacterial infection of the Stensen duct. About 75% of patients are 70 years old or older. The clinical course is rapid and fulminating, with severe cellulitis developing on the side of the face. Antibiotics and surgical drainage are the mainstays of treatment. Adequate hydration and good oral hygiene in the postoperative period are the best prophylaxis.

Option B (Closed fracture of the right zygoma) is incorrect. This would cause unilateral facial pain, and elderly homeless males are often the victims of assault or other trauma, but unless there is an open fracture, such an infective picture would not be usual.

Option C (Mumps) is incorrect. Mumps is an acute painful parotitis caused by a strain of paramyxovirus. It is less common in older age groups, and is highly communicable. Typically, it is a mild self-limiting condition, but there can be significant morbidity, such as mumps orchitis. With this complication, testicular damage leads to defective spermatogenesis and sterility.

Option D (Salivary gland tumor) is incorrect. Although oral cancers account for approximately 3% of all cases of cancer in the United States, salivary gland tumors are rare. Pleomorphic adenoma is the most common benign tumor. Malignant tumors include mucoepidermoid and adenoid cystic carcinomas. These tumors are painless and slow growing. They are not associated with an elevated WBC with a left shift.

Option E (Sjögren’s syndrome) is incorrect. This syndrome is recognized by a triad of dry mouth (xerostomia), dry eyes (xerophthalmia), and “dry joints” (chronic arthritis). Lymphocytic infiltration of the salivary and lacrimal glands occurs, which results in their enlargement and dysfunction. It is often associated with rheumatoid arthritis or other autoimmune diseases.

High-yield Hit 1
Mumps virus is a paramyxovirus and gains entry via the respiratory tract. The subsequent viremia allows access of the virus to tissues for which it has tropism, including salivary gland tissue, gastrointestinal tissue such as pancreas, testicular tissue and the central nervous system. The incubation period is 18-21 days.
page 464

page 465
Bacterial infection of the salivary glands is normally prevented by constant salivary flow, which removes contaminants from the ductal systems. Dehydration, xerostomia or obstruction of the ducts can lead to bacterial proliferation within the salivary glands and subsequent parotitis.

Taken from Infectious Diseases by Cohen.
High-yield Hit 2
The most common clinical manifestation is gradual onset of painful swelling of either one or both of the parotid glands, which occurs 14-21 days after contact with an infected individual. Pain within the parotid gland can be initiated by salivation during meals, and the glands are tender. Occasionally submandibular salivary glands are involved, but inflammation of sublingual glands is extremely rare. Orchitis is present in approximately 10-20% of individuals and is bilateral in 5%, but there is no firm evidence that it causes male sterility. Mumps meningoencephalitis may occur in concert with parotitis, but patients who have mumps meningitis often do not have parotitis. In the pre-MMR era mumps was a relatively common cause of viral meningitis in children less than 15 years old in whom permanent unilateral deafness was a recognized complication. Pancreatitis is rare. On examination there is smooth tender swelling that obliterates the angle of the jaw and may raise the pinna. Rarely, the outlet of Stensen's duct may be inflamed. There may be generalized symptoms, including fever, arthralgia, malaise and headache, that generally persist for up to a week. Culturable virus is present in the saliva for up to 1 week after gland enlargement. Management is essentially symptomatic.
Recurrent episodes of glandular swelling, particularly of the parotid gland, can occur in children with a history of mumps. Clinical features include recurrent parotid swelling with general malaise and pain frequently after a meal. Viridans streptococci are usually cultured from exudate from the Stensen's duct.
In primary bacterial parotitis there is usually rapid onset of pain, swelling and induration of the involved gland (Fig. 41.13). Manual palpation of the gland is exquisitely painful and can result in discharge of pus from the duct. In addition there are usually systemic features, including fever, rigors and a neutrophilia. The most frequently isolated organisms are Staph. aureus, Strep. pyogenes, viridans streptococci and Haemophilus influenzae.

Figure 41.13 Suppurative parotitis (a) in a diabetic patient who had a recent history of dehydration secondary to diabetic ketoacidosis. (b) Pus was manually expressed from Stensen's duct from which Staphylococcus aureus was cultured. Courtesy of Dr E Ridgway.
HIV-associated salivary gland swelling most commonly occurs as a bilateral cystic enlargement of the parotid glands, occasionally in association with xerostomia, dry eyes and arthralgia. Salivary gland involvement can occur very early on in HIV infection but is most commonly seen in late disease. Histologically, there are numerous epithelium-lined cysts, some up to several centimeters in size, containing macrophages and lymphocytes. The commonest identified opportunist infection of salivary glands is CMV; about 15% of postmortem submandibular glands of all patients who have AIDS have evidence of CMV inclusion bodies.35 In children, there is a strong association between HIV-parotid swelling and lymphocytic interstitial pneumonitis. Examination usually reveals smooth bilateral swelling. Uneven swelling should be biopsied because 10% of salivary gland disease in HIV-infected patients is caused by lymphoma.36
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Infectious-Diseases, Step-2-Questions, Surgery-

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