Abstract
The differential diagnosis of bilateral parotid gland enlargement in children includes infectious, inflammatory, and neoplastic disorders. We present the case of a 13-year-old male who presented with a 5-week history of bilateral parotid swelling. On exam, both parotid glands were nontender, smooth, and diffusely enlarged. He had slightly elevated inflammatory markers, but other lab results were normal. A neck CT revealed symmetric enlargement of the parotid, submandibular, and sublingual glands. A chest CT revealed scattered peripheral pulmonary nodules and bilateral hilar adenopathy. A parotid gland biopsy showed multiple noncaseating granulomas with multinucleated giant cells surrounded by lymphocytes, consistent with the diagnosis of sarcoidosis. Special stains for acid-fast and fungal organisms were negative. Using this illustrative case, we discuss the differential diagnosis of bilateral salivary gland enlargement in children and review the etiology, diagnosis, clinical manifestations, and treatment of pediatric sarcoidosis.
1
Introduction
The differential diagnosis of bilateral salivary gland enlargement in children includes a variety of infectious, inflammatory, and neoplastic disorders . Childhood sarcoidosis is a rare multisystem granulomatous disorder of unknown cause, usually characterized by nonspecific constitutional symptoms, pulmonary manifestations, lymphadenopathy, as well as skin and eye involvement . Although parotid gland enlargement is reported in sarcoidosis, the presentation is relatively uncommon . Early diagnosis of sarcoidosis in children is often difficult because of the lack of awareness and unfamiliarity with its clinical features and the disease may pose a diagnostic dilemma. We report an adolescent male with late-onset childhood sarcoidosis presenting as bilateral parotid gland enlargement and review the clinical features, laboratory findings, and treatment of this rare, enigmatic disorder.
2
Case report
A previously healthy 13-year-old African–American male presented with five weeks of bilateral, posterior jaw swelling. He reported mild nasal congestion and occasional headache, but denied fever, malaise, loss of appetite, pain, or difficulty with swallowing or eating. Past medical, family, and social histories were unremarkable.
Physical exam revealed a well-appearing male with normal vital signs. He had nontender, nonerythematous, smooth, diffusely enlarged parotid glands and mild bilateral, anterior cervical adenopathy. The nasal mucosa was erythematous with a mild, mucopurulent exudate. The remainder of the exam was normal. Initial laboratory tests revealed a C-reactive protein (CRP) of 1.6 mg/dL (normal ≤ 1.0) and erythrocyte sedimentation rate of 31 mm/h (normal < 20). Other lab results were normal including hemoglobin, platelet count, and leukocyte count and differential. A comprehensive metabolic panel, lactate dehydrogenase, and antibodies to Sjögren syndrome antigens A and B were also normal.
Because his symptoms persisted one month later, he was referred to a pediatric otolaryngologist, who obtained a neck computed tomography (CT) scan showing symmetric enlargement of the parotid, submandibular, and sublingual glands and chronic inflammation throughout the ethmoid and maxillary sinuses ( Fig. 1 ). A chest CT revealed scattered peripheral pulmonary nodules and bilateral hilar adenopathy. A parotid gland biopsy revealed multiple noncaseating granulomas with multinucleated giant cells surrounded by lymphocytes consistent with the diagnosis of sarcoidosis ( Fig. 2 ). Special stains for acid-fast and fungal organisms were negative. An ophthalmology exam was normal. Thyroid function studies, angiotensin-converting enzyme (ACE) level, and pulmonary function tests (PFTs) were normal.
Because this patient did not have symptomatic multisystem disease, he was observed without treatment and experienced complete resolution of the bilateral parotitis with no subsequent complications.
2
Case report
A previously healthy 13-year-old African–American male presented with five weeks of bilateral, posterior jaw swelling. He reported mild nasal congestion and occasional headache, but denied fever, malaise, loss of appetite, pain, or difficulty with swallowing or eating. Past medical, family, and social histories were unremarkable.
Physical exam revealed a well-appearing male with normal vital signs. He had nontender, nonerythematous, smooth, diffusely enlarged parotid glands and mild bilateral, anterior cervical adenopathy. The nasal mucosa was erythematous with a mild, mucopurulent exudate. The remainder of the exam was normal. Initial laboratory tests revealed a C-reactive protein (CRP) of 1.6 mg/dL (normal ≤ 1.0) and erythrocyte sedimentation rate of 31 mm/h (normal < 20). Other lab results were normal including hemoglobin, platelet count, and leukocyte count and differential. A comprehensive metabolic panel, lactate dehydrogenase, and antibodies to Sjögren syndrome antigens A and B were also normal.
Because his symptoms persisted one month later, he was referred to a pediatric otolaryngologist, who obtained a neck computed tomography (CT) scan showing symmetric enlargement of the parotid, submandibular, and sublingual glands and chronic inflammation throughout the ethmoid and maxillary sinuses ( Fig. 1 ). A chest CT revealed scattered peripheral pulmonary nodules and bilateral hilar adenopathy. A parotid gland biopsy revealed multiple noncaseating granulomas with multinucleated giant cells surrounded by lymphocytes consistent with the diagnosis of sarcoidosis ( Fig. 2 ). Special stains for acid-fast and fungal organisms were negative. An ophthalmology exam was normal. Thyroid function studies, angiotensin-converting enzyme (ACE) level, and pulmonary function tests (PFTs) were normal.
