Granulomatous pathology in salivary glands: a secondary health care center experience

Granulomatous pathology in salivary glands: a secondary health care center experience Malhotra P.1, Saraf A.2*, Bansal N.3 DOI: https://doi.org/10.17511/jopm.2020.i02.02 1 Pooja Malhotra, Specialist Pathology Grade I, Department of Pathology, ESIC Model Hospital, Baddi, Himachal Pradesh, India. 2* Ashish Saraf, Specialist Pathology, Department of Pathology, ESIC Model Hospital, Baddi, Himachal Pradesh, India. 3 Naveen Bansal, Medical Officer, Department of Pathology, ESIC Model Hospital, Baddi, Himachal Pradesh, India.


Introduction
Tuberculosis is a chronic illness that is more common in developing countries such as India. It mainly involves lungs and is characterized by granulomatous inflammation with or without caseous necrosis. Extrapulmonary forms of the disease account for 20 % of overall active tuberculosis and can affect any organ of the body. Clinically it presents as a slow-growing, painless and Female ratio was 2.2:1. The duration of illness was 1-12 months in 11 patients (68.75%), less than 1 month in 3 patients (18.75%) and more than 12 months in 2 patients (12.5%).
The parotid gland was involved in 14 patients (87.5%), whereas the submandibular gland was involved in 2 patients (12.5%). A family history of tuberculosis was present in 2 patients (12.5%) while a history of subjective weight loss was present in 1 patient (6.2%). One patient presented with recurrent parotid swelling, 9 months after an operation for parotid swelling. The size of predominant salivary gland swelling was less than 3 cm in 12 patients (75%) and ≥ 3 cm in 4 patients (25%). In 3 patients adjacent lymph nodes were also palpable.

Malhotra P. et al: Granulomatous pathology in salivary glands
Tropical Journal of Pathology and Microbiology 2020;6(2) The largest lymph node measured 1.3 cm approximately in maximum dimension. A complete blood count report was available in 7 out of 16 patients. Out of these 7 patients, the differential Monocyte count was more than 10 % in only 2 patients. Absolute monocyte count was less than the upper normal limit of 1000/mm3 in all the patients. Upon FNAC of the swelling, blood mixed Material was aspirated in 9 patients (56.2 %), pus was aspirated in 2 patients (12.5%), while whitish material and mucoid material were aspirated in one patient each (6.2 %). Both patients in whom pus was aspirated had a tender swelling. FNAC was repeated in 3 patients.
The microscopic findings of FNAC are shown in Table   2. Ziehl-Neelsen (ZN) staining was done in all patients and only 1 patient was positive for AFB. In one patient culture report from aspirated material showed mycobacterium species. FNAC is an easy and reliable outpatient procedure for the diagnosis of tubercular parotitis, and it is ideally suited for use in resource-limited settings, especially in developing countries. FNAC has a sensitivity of 81-100 % and specificity of 94-100 % in the diagnosis of parotid tuberculosis [10]. A total of 20.6 % of FNAC are non-diagnostic; which could be due to the complexity of tissue architecture.
However, this can be overcome by doing a repeat FNAC. Also, in the case of active infection, the FNAC report may be inconclusive [11]. FNAC was repeated in 3 out of 16 patients in the present study.
In the current study, FNACs of 38.1 % of the patients showed granulomatous inflammation ( Figure 1) and at least 11.9% of the swellings were likely due to tuberculosis. This is more as compared to the study by Van Der Walt et al in which 12.1% of the swellings showed granulomatous inflammation and only 1.9% of these swellings were due to tuberculosis [11]. This difference could be due to a lesser prevalence of tuberculosis in western countries. In the present study, 5 out of a total of 37 parotid FNACs (13.5%) were cases of parotid tuberculosis.

Conclusion
Although tuberculous parotitis is a rare entity, it should be always kept in mind as a differential What does this study add to the existing knowledge?
The present study emphasizes that FNAC is an easy and reliable investigation, which can help in the diagnosis of tubercular parotitis. As compared to the western data, our data shows that tuberculous parotitis constitutes a significant proportion of parotid swellings in India. Therefore, FNAC must be performed in all cases of salivary gland swellings for accurate diagnosis and treatment. Dr. Naveen Bansal prepared the final manuscript.

Author's contributions
All authors read and approved the final manuscript.