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August 2014, Volume 64, Issue 8

Letter to the Editor

Incessant cry - rare presentation of neonatal parotitis

Mukut Banerjee  ( Paediatric Medicine Department, Burdwan Medical College, Burdwan, West-Bengal, India. )
Tarak Nath Ghosh  ( Paediatric Medicine Department, Burdwan Medical College, Burdwan, West-Bengal, India. )
Sangita De  ( Paediatric Medicine Department, Burdwan Medical College, Burdwan, West-Bengal, India. )

Madam, An 18-day-old female neonate, otherwise healthy, presented with incessant cry for 2 days, increased during feeding. Baby was born out of non-consanguineous marriage. It was an institutional normal vaginal delivery, at term. The antenatal and postnatal period was uneventful. The baby was exclusively breastfed. On examination bilateral tender firm swellings were found in both parotid regions (Figure-1).

Neonatal reflexes, activities and vitals were normal. The other systemic examination revealed no detectable abnormality. Ultrasound examination of the swellings showed enlarged bilateral parotid glands. Over the next two days the swelling increased in size and involved both cheeks. Subsequently, the baby developed high grade fever with difficulty in sucking and purulent discharge from Stensen's duct. Investigations revealed increased Total Leucocyte Count of 23,500/cmm, with neutrophil 73%, lymphocyte 25%, monocyte 1%, eosinophil 1%, CRP 8mg/dl. Blood culture and culture from the discharge showed growth of staphylococcus aureus sensitive to amoxicillin-clavulanic acid. Cerebrospinal fluid study was within normal limit. Diagnosis was established by clinical examination and microbiology, and confirmed by ultrasonography (Figure-2).

The child was treated with amoxicillin-clavulanic acid and Gentamycin for14 days. She improved rapidly and was discharged after 2weeks of hospital admission.
Infection of salivary gland is very rare in neonates. After detail search, author found only 44 cases of neonatal suppurative parotitis in the literature in the last 44 (1970-2013) years.1-4 Most of the cases were male(77%), with involvement of unilateral parotid gland (77%). One third of these neonates were premature. Fever was reported in less than 50% of cases. Among these not a single neonate died of suppurative parotitis since 1970. Staphylococcus aureus is the most common causative organism. Other organisms known to be involved are Streptococcus pyogens, Streptococcus viridens, E. coli, Pseudomonas aeruginosa and N. catarrhalis.4 Dehydration, other congenital anomalies, prolonged orogastric feeding and septicaemia have also been associated with infective parotitis.1,5,6 Till date no definitive protective role of exclusive breast-feeding has been proved. Sometimes the only initial presentation of this condition may be incessant cry in an otherwise healthy neonate, specially increasing during feeding, as presented in our case. Infection of the parotid gland with Staph. aureus carries a good prognosis.7 If the swelling increases progressively in size, there is persistence of fever or there is presence of increasing fluctuation, when surgical intervention is required.5 Recurrence is very rare.6 Facial palsy, salivary fistula, mediastinitis, extension to the external auditory canal and abscess are common complications.4
To conclude, suppurative parotitis should be considered in the differential diagnosis in a neonate presenting with incessant cry for timely institution of specific therapy.

References

1. Spiegel, Morin D, Sakran W, Horovitz Y. Acute Neonatal suppurative parotitis: Case reports and review. Pediatric Infect Dis J 2004; 23: 76-78.
2. Ismail EA, Seoudi TM, AI-Amir M, AI-Esnawy AA. Neonatal suppurative parotitis over the last 4 decades: report of three new cases and review. Pediatr Int 2013; 55: 60-4.
3. Sabatino G, Verrotti A. Neonatal suppurative parotitis: A study of five cases. Eur J Pediatr 1999; 158: 312-314.
4. Leake D, Leake R. Neonatal suppurative parotitis. Pediatrics 1970; 46: 203-218.
5. Salaria M, Poddar B, Parmar V. Neonatal parotitis. Indian J Pediatr 2001; 68: 283.
6. David RB, O\'Connell EJ, Minn R. Suppurative parotitis in children. Am J Dis Child 1970; 119: 332-5.
7. Lindgren C, Balihodzic - Lucovic V. Aseptic sialadenitis in preterm infants associated with long term orogastric tube feeding. Eur J Pediatr 1998; 157: 1014-1016.

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