A 42-year-old woman with known HIV infection comes to the physician with left-sided facial swelling and pain. She describes similar episodes over the last 6 months that last several days and then slowly subside. During these episodes, she has difficulty eating and sleeping on her left side. She also complains of occasional dry mouth, heartburn, and nocturnal wheezing. Her CD4 count was 450/µL 2 months ago.
Her temperature is 36.7 C (98 F), blood pressure is 108/78 mm Hg, pulse is 70/min, and respirations are 16/min. There is a tender, nonerythematous, spongy swelling in the preauricular area extending to the angle of the mandible. Cranial nerve examination is unremarkable.
Which of the following is the most likely diagnosis?

Question

A 42-year-old woman with known HIV infection comes to the physician with left-sided facial swelling and pain.  She describes similar episodes over the last 6 months that last several days and then slowly subside.  During these episodes, she has difficulty eating and sleeping on her left side.  She also complains of occasional dry mouth, heartburn, and nocturnal wheezing.  Her CD4 count was 450/µL 2 months ago.
Her temperature is 36.7 C (98 F), blood pressure is 108/78 mm Hg, pulse is 70/min, and respirations are 16/min.  There is a tender, nonerythematous, spongy swelling in the preauricular area extending to the angle of the mandible.  Cranial nerve examination is unremarkable.
Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This patient's presentation is consistent with parotid gland swelling. Painful unilateral swelling of the parotid gland is usually due to gland obstruction (sialolithiasis) or infection (sialadenitis). Acute sialadenitis usually presents with swelling, pain, erythema, systemic symptoms (eg, fever, chills) and purulent drainage from the affected gland. This patient's absence of erythema and systemic symptoms makes sialolithiasis the more likely diagnosis. Risk factors for parotid stones include dehydration, smoking, trauma, gout, diuretics, and anticholinergic medicines. This patient's dry mouth may indicate decreased hydration leading to stone development or decreased salivary production due to obstruction. Preferred initial management is conservative with sialogogues (eg, lemon drops) to promote salivary secretion, moist heat to the affected area, massaging the gland to "milk" the duct, and adequate hydration. Patients with evidence of secondary infection should be started on antibiotics. High-resolution CT is the preferred diagnostic test for persistent disease or suspected complete obstruction. Surgery is reserved for disease refractory to conservative measures. (Choice A) Patients with HIV have an increased risk for lymphoma that may involve the parotid gland and usually presents with painless and focal glandular swelling. This patient's recurrent episodes of painful swelling make this less likely. (Choice B) Pleomorphic adenoma is the most common parotid tumor; patients with HIV have no additional risk for this tumor compared to the general population. As in lymphoma, patients usually present with painless and focal swelling. (Choice D) Sjögren's syndrome typically presents with xerostomia and keratoconjunctivitis sicca. The parotid gland may be involved, but patients usually have symmetrical bilateral painless swelling. (Choice E) Most cases of viral sialadenitis (eg, mumps, HIV infections) present with acute unilateral or bilateral parotid swelling with a prodrome of fever, malaise, headache, and myalgias. This patient's recurrent episodes and absence of systemic symptoms make this less likely. Educational objective: Unilateral painful parotid swelling is usually due to infection or parotid stone obstruction. Risk factors for stones include dehydration, smoking, diuretics, trauma, gout, and anticholinergic medicines. Lack of erythema and fever suggests stone obstruction. Therapy is supportive in nature, but high-resolution CT is the preferred diagnostic test for persistent disease or suspected complete obstruction. __________ References: Diagnosis and treatment of sialolithiasis. (http://www.ncbi.nlm.nih.gov/pubmed/15696881)

A 42-Year-Old Woman with Known HIV Infection Comes to the Physician