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Letters to the Editor Indian Pediatrics 2002; 39:407-408 |
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Suppurative Parotitis in a Neonate |
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A 14-day-old male newborn, full term normal delivery at hospital, with no perinatal or postnatal problems and with no history suggestive of infection in mother, presented with a swelling on right side of face since the past 2 days. The baby was exclusively breastfed. On examination he had tender, red indurated right parotid gland and purulent discharge from Stensen’s duct. Cry, activity, vitals, sucking and other neonatal reflexes were normal. Following day he developed a small abscess over dorsum of left foot and mild swelling with restriction of movements of right knee joint. Needle aspiration of parotid swelling revealed pus and that of right knee showed small quantity of serous fluid. Swelling on foot localized to a small abscess in next 2 days requiring incision and drainage. Staining of aspirates from all these sites showed Gram-positive cocci. Patient had been started on Cloxacillin and Gentamicin. Investigations revealed a TLC of 26,300/mm3 with 71.3% neutrophils, 27.4% lymphocytes, 1.3% eosinophils and band cell count of 28%, hemoglobin of 12.4 g/dl, serum amylase of 133 SU and negative HIVserology. Culture reports from blood and aspirates showed growth of methicillin resistant Staphylococcus aureus (MRSA) resistant to Cloxacillin and Gentamicin and sensitive to Vancomycin and Ciprofloxacin. These two antibiotics were started after stopping the earlier empirical therapy and were given for 21 days. Following this treatment, parotid and knee swelling rapidly regressed and did not require surgical drainage. He was discharged after 4 weeks of hospital stay. Acute suppurative infection of salivary gland is rare in neonatal period and occurs more frequently in preterm newborns(1). During a nine year study period, five cases of neonatal suppurative parotitis were detected in 3624 hospital admissions. The relative risk of developing neonatal suppurative parotitis in admitted infants was 5.52(2). Clinically, parotid suppuration is characterized by enlargement of one or both salivary glands, systemic symptoms and purulent discharge from Stensen’s duct. There is erythema of overlying skin(3). Sialastasis plays an important role in the causation of sialadenitis in neonate(1). In neonates prematurity, dehydration, congenital anomalies, prolonged orogastric feeding and septicemia have been associated with suppurative parotitis(2,3). Long term orogastric feeding may result in less ductal clearance of saliva, causing functional ductal obstruction and local inflammation(4). The protective role of exclusive breast-feeding in prevention of bacterial sialadenitis has not been defined. Parotid suppuration due to MRSA, as a initial presentation of septicemia in a healthy breastfed neonate is an unknown entity. Various organisms known to cause sialadenitis are Staphylococcus aureus, Streptococcus pyogenes, Streptococcus viridans, E. coli, Pseudomonas aeruginosa and N. catarrhalis(1). Staph. aureus is the most common organism responsible for this condition. Infection with Staph. aureus carries a good prognosis(5). The present case grew MRSA which responded well to appropriate antibiotic therapy. While 54% cases of sialadenitis in a series, were due to S. aureus all those who died (5/15) had infection with organisms other than S. aureus(1). Lack of expected improvement and presence of increasing fluctuation should prompt surgical incision and drainage(3). Neonatal parotitis is usually not associated with recurrences(4). Facial palsy, salivary fistula, mediastinitis and extension on to the external auditory canal can complicate suppurative parotitis(1). Any neonate, term or preterm, with evidence of salivary gland swelling should be carefully screened for the evidence of suppuration. Parotid suppuration could be an initial presentation of neonatal sepsis.
Sanjeev Managoli, |
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