A 43-year-old man is found wandering in the street in winter and is brought to the emergency department by a passing motorist. The patient is confused and unable to provide any history. He has no previous hospital records. On examination, there is mild hypothermia (temperature 35 C [95 F]), but vital signs are otherwise normal. The patient appears disheveled and lethargic but follows commands. The oral mucosa is moist, and there are extensive dental caries. The patient has no cervical lymphadenopathy, but there is bilateral, nontender swelling of the cheeks consistent with salivary gland enlargement. Which of the following is the most likely cause of this latter finding?

Question

A 43-year-old man is found wandering in the street in winter and is brought to the emergency department by a passing motorist.  The patient is confused and unable to provide any history.  He has no previous hospital records.  On examination, there is mild hypothermia (temperature 35 C [95 F]), but vital signs are otherwise normal.  The patient appears disheveled and lethargic but follows commands.  The oral mucosa is moist, and there are extensive dental caries.  The patient has no cervical lymphadenopathy, but there is bilateral, nontender swelling of the cheeks consistent with salivary gland enlargement.  Which of the following is the most likely cause of this latter finding?

Quizplus · Accepted Answer

This patient has nontender, bilateral enlargement of the parotid glands, which is consistent with sialadenosis. Sialadenosis is a benign, noninflammatory swelling of the salivary glands. It can result from overaccumulation of secretory granules in acinar cells (possibly due to abnormal autonomic innervation) in patients with chronic alcohol use, bulimia, or malnutrition. It can also result from fatty infiltration of the glands in patients with diabetes mellitus or liver disease. Sialadenosis presents with gradual enlargement of the glands that does not fluctuate and is not associated with eating. Recognition of this condition should prompt an investigation for underlying disease. Control of the underlying disease may improve (but usually not fully resolve) the glandular enlargement. (Choice B) Parotitis due to mumps can present with parotid swelling. However, it is typically painful and presents a few days after the onset of systemic symptoms (eg, fever, headache, myalgias). (Choice C) A pleomorphic adenoma is a benign salivary neoplasm that can present with painless enlargement of the parotid gland. However, the enlargement would be unilateral, and a distinct mass is typically palpated. (Choice D) Salivary stones (sialolithiasis) can block the flow of saliva out of the duct and lead to swelling due to increased fluid in the gland. However, swelling due to sialolithiasis is usually fluctuating, painful, and associated with eating (which stimulates saliva secretion). (Choice E) Sjögren syndrome can lead to bilateral swelling of the parotid glands due to lymphocytic infiltration. However, in contrast to this patient, it typically presents in women and is associated with dry mouth on examination (whereas this patient's mucous membranes are moist). (Choice F) Vitamin A deficiency often coexists with malnutrition, which can lead to sialadenosis. However, sialadenosis in these patients is probably related to protein malnutrition rather than vitamin A deficiency. Vitamin A deficiency most notably causes ocular manifestations, including impaired night vision, dry eyes, and keratinization of the conjunctivae and corneas. Educational objective: Sialadenosis is a benign, noninflammatory enlargement of the salivary glands, often caused by chronic alcohol use. References: Sialadenosis in patients with advanced liver disease. (http://www.ncbi.nlm.nih.gov/pubmed/19644542)

A 43-Year-Old Man Is Found Wandering in the Street in Winter