Cervicofacial Mycobacterial Infections Presenting as Major Salivary Gland Disease

Abstract

Mycobacterium tuberculosis and atypical mycobacterium are well-known causes of cervical lymphadenopathy, most often presenting without symptoms of systemic infection. These organisms may also directly involve the parenchyma of the major salivary glands and their periglandular or intraglandular nodes. The diagnosis of mycobacterial infections of the major salivary glands, compared to cervical lymph nodes, is equally--if not more--difficult to make. The differential must include the same spectrum of inflammatory and neoplastic diseases as well as lesions unique to the salivary glands. Selected cases are presented and discussed to show that principles established for the treatment of cervical mycobacterial infections must also be applied to major salivary gland infections. In particular, cutaneous fistulas may result from incisional biopsy or incision and drainage of the involved gland. Partial parotidectomy or submaxillary gland excision may be required, followed by multidrug, antituberculous chemotherapy for one to two years. Culturing of the organisms is extremely difficult, and the diagnosis of either mycobacterium tuberculosis or atypical mycobacterial infection must be based on a combination of history and clinical examination, skin testing, histopathology, acid-fast stains, culture, and response to surgery and antituberculous chemotherapy.

Lymphadenitis due to <i>Mycobacterium terrae</i> in an Immunocompetent Patient

“…In general, systemic infection caused by Mycobacterium, which usually occurs in immunosuppressed patients, is uncommon and has a poor prognosis [14, 15, 16, 17]. We report here the first case of systemic lymphadenitis due to M. terrae in a normal host.…”

Mycobacterium fortuitum–induced persistent parotitis: Successful therapy with clarithromycin and ciprofloxacin

“…In the past, NTM generally have shown poor in vitro susceptibility to standard antituberculous drugs, 14 and many authors have recommended surgical interventions including partial or total parotidectomies for NTM infection of the parotid gland lymph nodes. 13,15,16 Conversely, many studies show that clarithromycin, amikacin, cefoxitin, fluoroquinolones (ciprofloxacin and ofloxacin), doxycycline, imipenem, and sulfonamides have good in vitro activity against M. fortuitum. 17,18 A combina- tion of 2 or more agents should always be utilized, as with all mycobacterial infections, to avoid drug resistance.…”

Tuberculosis of the Parotid Gland

“…In most published series, diagnosis was not made preoperatively, even when there were associated systemic manifestations. 1,6 Mycobacterial infection could be present despite normal chest x-ray studies, negative skin tests, negative stains for AFB, and even negative cultures. These negative results occur more commonly with atypical mycobacterial infection.…”

“…10 However, this imaging technique together with technitium 99m pertechnetate scintigraphy, sialography, and sonography do not give pathognomonic signs for tuberculosis. 10,11 Ziehl-Neelsen staining for AFB has been reported to be positive in 20 to 50% 6 and 44% 8 of patients with positive skin tests and histopathologic findings consistent with tuberculous cervical lymphadenitis. Positive cultures are even less reliable.…”

“…7,13 Recurrence after surgery was reported to be 33% compared with an 11% recurrence after combined therapy. 6 Superficial parotidectomy or submandibular sialoadenectomy should be followed by multidrug antituberculous chemotherapy for 18 to 24 months. Isoniazid, ethambutol, rifampicin, and pyridoxine are used in different combinations in different institutions.…”