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Clinical Problem Solving: Pathology
February 2002

Pathology Quiz Case

Author Affiliations
 

FREDERIC B.ASKINMDWILLIAM H.WESTRAMD

Arch Otolaryngol Head Neck Surg. 2002;128(2):195. doi:10.1001/archotol.128.2.195

AN OTHERWISE healthy 26-year-old white woman presented with bilateral parotid gland swelling in January 2000. She reported that she had had a severe bout of mononucleosis in November 1999, with fevers, chills, odynophagia, fatigue, severe myalgias and arthralgias, and enlarged parotid glands. Further history revealed occasional dry eyes, dry skin, and a "clicking" with swallowing. She denied shortness of breath, cough, dysphagia, odynophagia, skin lesions, and recent weight loss. Except for persistent parotid swelling, her symptoms had resolved. Before presenting at our clinic, she had received 4 short courses of corticosteroids that had significantly reduced the swelling.

The results of the head and neck examination were unremarkable except for nontender swelling of the parotid glands, which was greater on the left side (Figure 1). The pulmonary, cardiac, abdominal, skin, and extremity examinations revealed no abnormalities. Laboratory tests were negative for antinuclear antibodies, rheumatoid factor, and anti-nuclear riboprotein antibodies. The erythrocyte sedimentation rate and complete blood cell count were normal, as were the results of serum chemistry studies. The angiotensin-converting enzyme level was elevated at 76 U/L (reference range, 18-55 U/L). The mumps IgG titer was positive at 1.89 g/L, which was consistent with prior immunization. The chest radiograph did not demonstrate hilar adenopathy or parenchymal disease. Computed tomography of the head revealed bilateral parotid gland enlargement with uniform density (Figure 2). Fine-needle aspiration of the parotid glands revealed blood elements with rare stromal fragments. A touch preparation obtained from the left parotid gland showed a mixed B- and T-cell population consistent with a reactive pattern, but the findings were nonspecific. A biopsy specimen from the left parotid gland revealed numerous noncaseating granulomas. The histopathologic features are shown in Figure 3 and Figure 4. Stains for fungi and acid-fast bacilli were negative.

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