When Mumps is Not the Diagnosis: Acute Sialadenitis During Influenza Season Tasha Desai, DO and Tibisay Villalobos-Fry, MD Children’s Hospital at Lehigh Valley Health Network, Allentown, Pennsylvania

Differential Diagnosis of Sialoadentitis Atypical Presentations of Influenza Background Results Viral Images • Coxsackie virus • Adenovirus • Sialadenitis/parotitis • Influenza A virus • Epstein-Barr virus • Croup Patient 1: • Parainfluenza virus • Varicella-zoster virus • Bronchiolitis During the winter of 2014-2015, there were • Cytomegalovirus • Pneumonitis/pneumonia • Adenovirus • Encephalitis a significant number of children diagnosed 10 year old male • Epstein-Barr virus • PANDAs with acute sialadenitis or parotitis from the • Symptoms: facial swelling, mouth sores, fever, rhinorrhea, sore throat • Varicella-zoster virus • Myocarditis • Signs: bilateral parotitis; oral mucosal ulcers Bacterial emergency department with presenting • Staphylococcus aureus • Peptostreptococcus • Diagnostic testing: CMV/EBV/Mumps titers, respiratory viral panel PCR • Alpha-hemolytic Streptococcus • Prevotella complaints of URI symptoms and sore • Streptococcus pyogenes • Fusobacterium • Result: Influenza A • Haemophilus influenzae • Bacteroides throat. In recent years, several states have • Escherichia coli • Actinomyces • Klebsiella pneumoniae • Mycobacterium reported outbreaks of mumps cases, and Patient 2: • Pseudomonas aeruginosa • Bartonella • Pseudomonas pseudomallei • Salmonella initial work-up was aimed to rule out this 11 year old female with nephrotic syndrome • Eikenella corrodens • Treponema particular viral infection. As several of these • Symptoms: facial swelling, jaw pain with mastication, fever children were also diagnosed with Influenza, • Signs: bilateral parotitis this led to the hypothesis of Influenza as • Diagnostic testing: UA, CBC, CMP, respiratory viral panel PCR • Result: Influenza A/H3 Figure 1. Bilaterally enlarged submandibular glands Figure 2. Bilaterally enlarged submandibular Conclusion: the cause of sialadenitis/parotitis. Literature with intraglandular ducts (red arrows). Scattered jugular, glands with dilated intraglandular ducts (red arrows). submandibular, submental, and retropharyngeal reactive Retropharyngeal fluid collection without rim enhancement search wielded few prior reports describing Patient 3: lymph nodes (orange arrows). (yellow arrows). Multiple reactive lymph nodes. Acute parotitis or sialadenitis during the winter months association between Influenza A and acute 20 year old female with history of asthma can be due to Influenza A infection, even without the parotitis in the pediatric population, with presence of systemic symptoms typical of Influenza. In • Symptoms: fever, URI symptoms, cough, neck swelling, sore throat Table 1. Patient Demographics and Symptoms most recent published cases reporting • Signs: bilateral submandibular lymphadenopathy fully vaccinated children in whom Mumps is ruled out, Time of Congestion/ Sore acute parotitis secondary to Influenza H3/N2 • Diagnostic testing: CBC, CRP, Monospot, blood culture, CT neck, EBV/ Age Gender Presentation Chief Complaint Rhinorrhea Cough Throat Fever Test Results Influenza virus infection should be included in the list of CMV/Baronella titers, respiratory viral panel PCR subtype. 5 Male October Post-auricular swelling - + - - N/A differential diagnoses of acute sialadenitis. • Result: Influenza A/H3 Male October Facial swelling - - - - N/A - CT: bilateral sialadenitis, suspected transudate in the retropharynx, 15 Methods multiple reactive lymph nodes 6 Male November Facial swelling - - - - N/A References: 2 Male November Post-auricular swelling Croup + N/A 1. Bastien N, Bowness D, et al: Parotitis in a Child Infected with Triple-Reassortant Influenza, A Virus in Canada in 2007. Journal of Clin Microbiology 47:1896-1898, 2009. Institutional chart review was performed for 16 Male December Facial swelling + - + - N/A Patient 4: 2. Battle S, Laudenbach J, Maguire J: Influenza Parotitis: A Case from the 2004 to 2005 Vaccine Shortage. So Society for Clin pediatric cases of facial swelling, revealing 7 Female December Facial swelling - - - - N/A Investigation 333: 215-217, 2007. 3. Brill S, Gilfillan R: Acute Parotitis Associated with Influenza Type A. N Engl J Med 296:1391-1392, 1977. 14 year old male 10 Male December Facial swelling + - + + Influenza A 12 cases with diagnoses of acute parotitis 4. Centers for Disease Control. Update – Influenza Activity.MMWR 2015; 64: 206-212. • Symptoms: sore throat, cough, bilateral neck swelling, “congested 11 Female November Facial swelling - - - + Influenza A/H3 5. Davidkin I, Jokinen S, et al: Etiology of Mumps-Like Illnesses in Children and Adolescents Vaccinated for Measles, Mumps, or sialadenitis between October 2014 and and Rubella. 191: 719-723, 2005. voice” Female December Neck swelling + + + + Influenza A/H3 J Infect Dis January 2015. Due to the presence of URI 20 • Signs: bilateral submandibular gland swelling 14 Male December Neck swelling - + + - Influenza A Acknowledgements: symptoms and sore throat, 4 cases had We thank Teresa Romano, MD and Kenneth Rachwal, PA-C for assisting in data collection. We also thank Alexander Kowal, MD • Diagnostic testing: CBC, BMP, blood culture, EBV titers, rapid Flu/RSV 10 Male December Neck swelling + + + + N/A for discussing radiology findings as depicted. diagnostic influenza testing. All 4 samples PCR, CT neck 12 Female January Jaw swelling + + + N/A were nasopharyngeal swabs collected for • Result: Influenza A © 2015 Lehigh Valley Health Network 1 - CT: infectious inflammatory changes involving the retropharynx PCR testing (Luminex panel - xTAG® or and danger space, with no abscess; edematous changes involving Focus Simplexa2) performed by the same the aryepiglottic folds Footnotes: hospital-affiliated laboratory. 1. Luminex tests for Respiratory Syncytial Virus (RSV and A&B, Influenza (A Matrix, H1 subtype, H3 subtype, B), Parainfluenza (A, B, C), Metapneumovirus, Adenovirus, Rhinovirus. All 4 patients recovered without complications. 2. Focus Simplexa tests for Influenza (A, B), RSV.