From Volume 52, Issue 2, February 2025 | Pages 134-136
This report describes the case of a patient with Sjögren's syndrome who presented with acute suppurative parotitis. A microbiological test of the purulent discharge obtained from the right parotid duct revealed the condition was secondary to acute
Acute sialadenitis in patients with secondary Sjögren's syndrome is not uncommon1 and is often immediately considered to be bacterial in nature. Although this assumption is well grounded in evidence, given the increased risk of localized blockage of the salivary gland, there remain incidences where, despite antibiotic prescription, the infection persists. We present such a case here. Candida is a common opportunistic infection in immunocompromised patients as well as in those with a dry mouth. Candidal abscess of the salivary gland has been reported but its signs and symptoms mimic that of acute bacterial infection; (low grade fever (37.4–37.8°C), painful inflammatory-mediated swelling, and salivary gland duct discharge).1–3 As such, when managing patients with salivary gland infection, alternative causative agents should be considered to ensure antibiotic stewardship and provide optimal care.
A 52-year-old female presented to the dental emergency clinic at Newcastle Dental Hospital complaining of a painful swelling on the right side of her face. The swelling had been present for 1 week and was suspected to be of dental origin by her general medical practitioner. The patient was known to have secondary Sjögren's syndrome, alongside rheumatoid arthritis, vasculitis and hypothyroidism.
On examination, extra-orally there was a unilateral, fixed swelling in the parotid region (Figure 1). The overlying skin demonstrated rubor (Figure 2) and was warm to palpation. Clinical observations showed there was no pyrexia. Intra-orally there was pus expressed from the right parotid duct (Figure 3) and there was also marked dryness of the oral mucosa (Challacombe scale 8).4 The patient was partially dentate and had a moderately restored dentition with no obvious dental pathology from the upper right or lower right quadrant. A differential diagnosis of acute bacterial sialadenitis was made. Local drainage through the duct was encouraged with manual palpation until no further pus could be expressed from the duct. In response to the swelling, the patient had been prescribed 500 mg flucloxacillin by her general medical practitioner and was therefore advised to complete this as the firstline antibiotic for this condition.5
An intra-oral swab of the pus present was taken, and an urgent ultrasound ordered to rule out the possibility of lymphoma.6 The patient was to be reviewed after 2 weeks.
The results of the ultrasound determined no presence of lymphoma and was in keeping with acute parotitis complicated by a mucous plug present in the duct (Figure 4). The mucous plug was attributed to Sjögren's syndrome and had been present in previous ultrasounds taken of the gland and duct. The only species isolated from the swab of pus from the right parotid duct was Candida albicans. On review, and having completed her course of antibiotics, the patient reported an improvement in pain, but little improvement in swelling. Intra-oral examination showed continued presence of pus from the right parotid duct and presence of white plaques in the buccal sulcus. Given that the candida species had been isolated from the pus, a 7-day course of 50 mg fluconazole to be taken once daily was prescribed7 and no further antibiotics was prescribed to the patient.
The patient was reviewed following completion of the course of fluconazole. On examination, facial symmetry had returned, and no swelling was noted. The patient reported all pain had resolved and she was discharged from the dental emergency clinic and referred for a sialoendoscopic approach to evacuate mucous from the duct.
Patients with acute bacterial sialadenitis typically present with a painful unilateral swelling and discharge from the associated duct. The differential diagnosis is made from this presentation, yet the underlying cause of the acute presentation is not so easily determined. Locating a mucous plug blocking the duct and the microbiology results revealing that Candida was the only isolated species led us to the conclusion of an acute candidal infection. This would not have been noticed until the results of the microbiology swab. Given the history of Sjögren's syndrome, this predisposed the patient to higher risk of acute oral candidosis,2 the acute infection of the duct and the parotid gland by the same species ought to have been a differential diagnosis and another consideration in her presentation. The continued presence of pus highlighted an unsuccessful outcome from flucloxacillin use and supported need for further treatment. Without the use of a swab, it is unlikely an antifungal would have been prescribed rather more antibiotics, which would have only impacted secondary bacterial infection and not treated the primary cause of the condition. It is acknowledged that mouth swabs for use for definitive microbiological testing may not be as preferred as more technique-demanding testing, such as an aspirate.7 In spite of this, the response of the parotid swelling to the fluconazole demonstrates a fungal involvement in this patient's swelling.
The literature reports fungal infection as a rare cause of parotid abscesses, and this is attributed to the impact of saliva on fungi in normal conditions.8,9C. albicans is, however, one of the more common fungal species to cause an acute sialadenitis in compromised health.10 This is more commonly reported in immunocompromised patients10 or those with diabetes,1 that is those with high risk for developing oral candidosis. A patient with Sjögren's syndrome ought to be considered in this category. Other reports of acute candidal infection in the parotid gland support use of local drainage and oral fluconazole prescription11 which was employed successfully in this case but there is no standardized approach to this in the literature.
This case supports the use of microbiology testing where available to support diagnosis and treatment planning, and highlights other infectious causes of acute suppurative parotitis in patients with Sjögren's syndrome. The increased incidence of candidal infection in these patients predisposes them to this rarer impact on the parotid gland and inclusion of this in the differential diagnosis will benefit both the patient and the clinician who is faced with an unusual outcome to a common presentation in these patients.
