A 46-year-old male presenting with a painful 4×4 cm right parotid neck mass, fever, and severe dysphagia was diagnosed with a unilateral parotid abscess nested within a Warthin’s tumour, driven by systemic Brucella melitensis infection, as documented in a case report published by Cureus.
In Plain English: The Clinical Takeaway
- What happened: A patient developed a rare deep-seated infection of the salivary gland called a parotid abscess, which grew directly inside a benign (non-cancerous) tumor known as a Warthin’s tumour.
- The underlying cause: Blood tests and fluid cultures confirmed the infection was caused by Brucella melitensis, a zoonotic bacterium typically transmitted through unpasteurized dairy products or direct contact with infected livestock such as camels.
- The treatment: Doctors performed targeted needle aspirations to drain the pus and administered a strict 14-day intravenous and oral antibiotic regimen consisting of gentamicin and doxycycline.
Emergency Admission and Diagnostic Workup of a Parotid Mass
The patient arrived at the Emergency Department complaining of a progressive, painful mass on the right side of his neck spanning the past month, accompanied by painful swallowing and an auxiliary temperature of 38.5°C. Physical examination revealed an erythematous, hard mass over the right parotid gland extending toward the sternocleidomastoid muscle, alongside poor dental hygiene and dehydration. Blood investigations exposed severely uncontrolled diabetes mellitus with a glycated haemoglobin (HbA1c) level of 12.21% and significantly elevated inflammatory markers, including a C-reactive protein (CRP) level of 107.5 mg/L.
Initial intravenous antibiotic administration of ceftriaxone and clindamycin failed to resolve the swelling within 24 hours. A subsequent computed tomography (CT) scan of the head and neck confirmed a multiloculated, heterogeneous, peripherally enhancing right parotid lesion measuring 5.5 × 4.5 × 2.1 cm with adjacent inflammatory fat stranding and upper cervical lymphadenopathy. Serological testing returned a positive Brucella melitensis antibody titre of 1:640, substantially above the negative threshold of less than 1:160. Concurrently, PMC.ncbi.nlm.nih.gov documented a parallel clinical presentation in a 65-year-old female with primary Sjögren’s syndrome who similarly developed a suppurative parotid abscess secondary to brucellosis, exhibiting elevated erythrocyte sedimentation rates and a systemic inflammatory response, establishing a rare precedent for salivary gland involvement in systemic brucellosis.
Surgical Drainage and Targeted Antimicrobial Therapy
To definitively identify the pathogen and pathology, the patient underwent needle aspiration of the abscess alongside a needle core biopsy of the right parotid gland. Pus cultures isolated Brucella melitensis, while histopathology of the cream-tan tissue fragments confirmed the presence of a Warthin’s tumour. Transitioning away from broad-spectrum coverage, the clinical team initiated a targeted regimen of intravenous gentamicin and doxycycline based on specific sensitivity results. Repeated ultrasound-guided aspirations facilitated substantial evacuation of purulent material.
A follow-up CT scan performed four days post-procedure demonstrated interval enlargement with internal air foci—attributable directly to air introduced during aspiration—coupled with localized fluid reaccumulation. Despite this radiological artifact, the patient achieved marked symptomatic relief and maintained clinical stability. He was successfully discharged following a complete 14-day antimicrobial course.
| Clinical Parameter | Patient Admission Value | Standard Reference Range |
|---|---|---|
| Glycated Haemoglobin (HbA1c) | 12.21% | < 5.7% |
| C-Reactive Protein (CRP) | 107.5 mg/L | < 5.0 mg/L |
| Brucella melitensis Titre | 1:640 (Positive) | < 1:160 (Negative) |
| White Blood Cell (WBC) Count | 9.1 × 10⁹/L | 4.0–11.0 × 10⁹/L |
Anatomical Predisposition and Zoonotic Risk Factors
Warthin’s tumour represents the second most common benign salivary gland neoplasm, accounting for up to 15% of primary epithelial parotid tumors, with a distinct predilection for male smokers. The structural architecture of these tumors features cystoid, fluid-filled cavities and prominent lymphoid tissue, creating an ideal milieu for microbial stasis and secondary infection. In this patient, concurrent poorly controlled type 2 diabetes mellitus induced microvascular compromise, compounding his occupational exposure to camels to facilitate systemic bacterial seeding into the parotid parenchyma.
Cureus noted that while brucellosis maintains a seroprevalence of approximately 20% in regions such as Saudi Arabia, head and neck manifestations remain exceedingly rare, with parotid abscesses secondary to Brucella documented in only a tiny fraction of global literature. PMC.ncbi.nlm.nih.gov similarly emphasized that systemic zoonotic infections frequently mimic autoimmune or malignant pathologies in patients presenting with unilateral salivary swelling, demanding comprehensive serological screening in endemic zones.
Contraindications & When to Consult a Doctor
Patients presenting with acute, painful unilateral parotid swelling, persistent localized erythema, fever, or difficulty swallowing must seek immediate medical evaluation by an otolaryngologist or infectious disease specialist. Diagnostic workups must rule out deep neck space infections, Ludwig’s angina, and structural salivary malignancies prior to executing surgical drainage. Individuals undergoing treatment with tetracycline-class antibiotics like doxycycline must avoid usage during pregnancy or in pediatric populations due to risks of permanent tooth discoloration and skeletal development inhibition. Furthermore, patients with uncontrolled hyperglycemia or immunocompromising states require aggressive metabolic stabilization alongside antimicrobial interventions to prevent sepsis and mediastinal extension.
Six-month follow-up evaluations conducted jointly by the infectious diseases clinic and the otorhinolaryngology team confirmed complete resolution of presenting symptoms, continued regression of the parotid mass, and an absence of long-term cranial nerve or systemic complications.
References
- Cureus: Unilateral Parotid Abscess Within a Warthin’s Tumour Secondary to Brucellosis: A Case Report.
- PMC (PubMed Central): Parotid abscess secondary to brucellosis in a patient with Sjögren’s syndrome. PMC6063305.
