Case Report: Suppurative Parotitis Secondary to Sjögren’s Syndrome Complicated by Nontuberculous Mycobacterial Infection

Case Report: Suppurative Parotitis Secondary to Sjögren’s Syndrome Complicated by Nontuberculous Mycobacterial Infection | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Case Report: Suppurative Parotitis Secondary to Sjögren’s Syndrome Complicated by Nontuberculous Mycobacterial Infection Tingjun Cao, Qianqian Bu, Ye Liu, Yuan Wang, Jiayan Qian, Zihui Huang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6818387/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background: Sjögren’s Syndrome (SS) is a chronic autoimmune disease characterized by dysfunction of exocrine glands. Chronic recurrent parotitis is a common complication, but progression to suppurative parotitis, especially when caused by nontuberculous mycobacterial (NTM) infection, is rare and often misdiagnosed. Case presentation: We report a case of a 44-year-old woman with a 6-year history of SS who presented with left parotid swelling unresponsive to conventional antibiotics. Symptoms worsened after parotid duct irrigation. Imaging revealed multiple abscesses, and pus culture finally confirmed Mycobacterium abscessus complex (MABC). After receiving targeted antimicrobial therapy with clarithromycin, amikacin, and moxifloxacin, combined with surgical incision and drainage,the patient achieved complete recovery and was successfully discharged. Conclusions: Clinicians should consider NTM infection in SS patients with recurrent or treatment-resistant parotitis, especially after invasive procedures. Early microbial identification and drug sensitivity testing are essential to guide an appropriate therapy. Combined medical and surgical management can lead to favorable outcomes. Sjögren's Syndrome Suppurative Parotitis Nontuberculous Mycobacteria Infection Mycobacterium Abscessus Complex Parotid Duct Irrigation Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background SS is a chronic autoimmune disorder that involves immune-mediated dysfunction of exocrine glands, with a focus on the salivary and lacrimal glands. It commonly results in the severe dryness of mucosal surfaces, principally in the mouth and eyes [ 1 ] . Patients with SS often exhibit recurrent parotid swelling, commonly referred to as chronic recurrent parotitis or suppurative parotitis [ 2 , 3 ] . Acute suppurative infections and severe systemic inflammatory reactions can occur in some patients [ 4 ] , but are rarely reported. NTM are genera of mycobacteria other than Mycobacterium tuberculosis complex and Mycobacterium leprae, which are widely found in the environment such as water, soil, and air. They usually lead to chronic lung infections in patients with structural lung disease.Only a minority affecting extrapulmonary tissues, including Skin and Soft Tissue Infections (SSTI) [ 5 ] . MABC is one of the fast-growing strains of NTM. Although rarely reported, it usually results to extrapulmonary infections, especially SSTI, usually manifest as papules, pustules, nodules, abscesses, seborrhea, folliculitis, or plaques. These lesions present with erythema and violaceous plaques frequently, typically without increased skin temperature. In advanced stages, the lesions may progress to skin ulcers [ 6 ] . In recent years, with the widespread use of immunosuppressants and the improvements in pathogen diagnostic techniques, the detection rate of MABC infections in skin and soft tissues has gradually increased, warranting attention [ 7 ] . This article reports a rare case of SS-secondary suppurative parotitis complicated by NTM (MABC) infection. After identifying the infection source and implementing targeted therapy, the patient achieved a favorable outcome. Case presentation The patient is a 44-year-old female diagnosed with SS in August 2018. She took hydroxychloroquine sulfate tablets intermittently and irregularly, and stopped taking the medication 6 months ago. Over the past six years, she experienced recurrent bilateral parotid gland swelling, and responded well to antibiotic therapy. On January 21, 2024, swelling and pain around the left ear occurred again. Despite multiple courses of conventional antibiotic treatment, no significant improvement was observed. On February 5, following saline irrigation of the left parotid duct, her symptoms worsened with marked swelling, palpable fluctuation and increased local skin temperature (Fig. 1). She was admitted to the hospital. Physical examination revealed a markedly enlarged left parotid gland, about 5×4 cm in size.The gland is hard as stone, with unclear boundaries and pronounced tenderness. The central skin exhibited a dark red discoloration, accompanied by palpable fluctuation and increased skin temperature. Additionally, there was a shallowening of the left nasolabial fold, deviation of the mouth corner, and restricted mouth opening to the extent of only one finger. Examination of the intraoral parotid duct orifice did not reveal the presence of pus. On admission, blood routine tests showed neutrophils 77.50% (normal range 40.00–75.00%), lymphocytes 14.40% (20.00–50.00%). Erythrocyte sedimentation rate was 55.00 mm/h (0.00–20.00 mm/h), rheumatoid factor was 226.99 IU/mL (0.00–20.00 IU/mL). Anti-SSA antibody was positive, while anti-SSB antibody was negative. PAS: negative. Liver and kidney function, electrolytes, procalcitonin, coagulation function, urinalysis, stool routine, and tests for syphilis and HIV antibodies showed no obvious abnormalities. Ultrasonography (Fig. 2:a.b.) and radiological imaging (Fig. 2:c.d.) showed diffuse lesions in both parotid glands with multiple abscess formations on the left sid. Under ultrasound guidance, pus was aspirated from the abscess area for culture. Pathogen examination showed positive for NTM (Fig. 3). Based on the results of drug sensitivity testing and NTM treatment guidelines, the patient was initiated on a combination therapy comprising clarithromycin 500mg twice daily, amikacin injection 0.8g once daily, and intravenous moxifloxacin 0.4g once daily. After treatment, the lesion in the parotid gland localized, the local abscess ruptured. Consequently, a left parotid abscess incision and drainage procedure was performed, during which the necrotic tissue was debrided, and a small amount of pus was drained. The histopathological examination: epithelioid granulomas (Fig. 4, Pathology No. 202401329). After continuing the original treatment regimen for 2 weeks, the wound healed, the parotid swelling completely resolved (Fig. 5), and the facial appearance returned to normal. The patient was discharged with instructions to continue the current treatment, take SS medications regularly, and follow up regularly. Discussion and conclusions SS is a chronic inflammatory auto-basic immune disease, which is mainly characterized by a decrease in saliva and tear secretion [ 2 ] . Reduced salivary flow can lead to stagnation within the long and narrow parotid ducts, increasing the risk of ductal obstruction. At the same time, reduced antimicrobial activity in saliva allows oral bacteria to more easily migrate retrogradely into the ducts. Therefore, SS often affects the parotid glands, leading to recurrent episodes of inflammation and swelling, termed chronic suppurative parotitis secondary to SS. Clinically, it often presents as repeated mild bilateral parotid swelling accompanied by mild pain, and usually without systemic manifestations [ 8 ] . Early administration of broad-spectrum antibiotics targeting Gram-positive cocci can effectively relieve the inflammatory response. Parotid duct perfusion is also a beneficial approach of treating chronic parotitis [ 9 ] . By flushing the parotid gland with injectable drugs, the inflammatory purulent secretions can be discharged and their retention and absorption can be reduced. Besides, the direct delivery of therapeutic agents to the site of inflammation aids in controlling and relieving the condition [ 9 ] . In this case, the patient suffered from SS for 6 years and had repeated parotid gland enlargement, which always could be relieved by the conventional anti-infective treatment mentioned above. Before the onset of this time, the patient had stopped taking hydroxychloroquine sulfate tablets for 6 months, which may have caused an imbalance in the autoimmune function (anti-SSA antibody positive, anti-SSB antibody negative). So the immune system could not correctly recognize normal cells and tissues, resulting in damage to normal glands, which leads to glandular hypofunction, manifested as swollen glands and infections due to the retrograde movement of bacteria from the oral cavity [ 8 ] . Consequently, the anti-infection treatment for the gland alone cannot solve the root cause of the immune disorder and glandular hypofunction, so the early anti-infection treatment has no obvious effect. Ductal irrigation of the parotid gland is generally effective in managing chronic parotitis. However, during acute exacerbations, significant glandular edema and pain are often present, and performing intraductal irrigation at this stage may damage the parotid duct, potentially exacerbating glandular swelling and worsening the condition [ 10 ] . In this case, the patient's swelling was worse after irrigation, and it was evident that the infection still existed and gradually involved the whole gland. It can be hypothesized that the inflammation was exacerbated due to the inappropriate perfusion in the acute phase. On the other hand, parotid ductal irrigation, as an invasive treatment, may also be a direct cause of the invasion of exogenous pathogens. At this point, observing the patient's parotid area under ultrasound, we found multiple microabscesses and subcutaneous abscess formation, confirming the presence of infection. In order to develop a rational and effective anti-infection program, it is essential to identify the pathogen to the strain level and perform drug sensitivity tests. In order to avoid further spreading of the inflammation by accidental injury to the parotid tissue during puncture and to ensure the accuracy of sampling, we took pus from the suppurating area of the lesion under the guidance of ultrasound for pathogenetic examination. And finally, we isolated NTM and identified them at the species level as an infection caused by the MABC. NTM is ubiquitous in soil and water, posing as an opportunistic pathogen that frequently targets immunocompromised hosts [ 11 ] . These microorganisms exhibit a high degree of antibiotic resistance, and there are notable differences in antibiotic susceptibility among different bacterial species [ 12 ] . So further species identification is typically required to determine the optimal treatment strategy. Currently, DNA sequencing is the most accepted method for the identification and characterization of NTM species and subspecies, while whole genome sequencing (WGS) is considered the gold standard for species-level identification [ 13 ] . MABC stands out as a prevalent cause of skin and soft tissue infections, particularly in association with foreign body implants and other invasive procedures [ 14 ] .The clinical manifestations of MABC infections closely resemble those caused by Mycobacterium tuberculosis (MTB), yet their treatment modalities differ significantly. Therefore, it is essential to exclude MTB and confirm NTM infection. Notably, MABC exhibits resistance to first-line anti-tuberculous drugs, necessitating the administration of macrolides (such as clarithromycin 500mg twice daily) in conjunction with one or more additional sensitive antibiotics for a minimum duration of 4 to 6 months [ 15 , 16 ] . Additionally, surgical intervention, including incision and drainage of abscesses, is necessary to reduce bacterial load, alleviate local pressure, and facilitate wound healing by eliminating necrotic tissues and preventing bacterial dissemination [ 3 ] . In line with the susceptibility test results for the isolated MABC strain, the patient was prescribed clarithromycin 500mg orally twice daily, amikacin injection 0.8g daily, and moxifloxacin injection 0.4g intravenously daily. Once the abscess matured, local surgical debridement was performed to evacuate pus and necrotic tissue to reduced local pressure, eased swelling, and prevented bacterial proliferation and spread to surrounding tissues. The procedure also created a favorable environment for wound healing. After maintaining this treatment regimen for two weeks, the patient discharged with complete wound healing and resolution of parotid gland swelling. She was instructed to continue medication until completion of the prescribed course to ensure adequate plasma drug concentrations, eradicating the pathogen, and minimizing the risk of developing drug resistance. The treatment regimen should be dynamically adjusted based on the antimicrobial susceptibility of the isolated pathogen during therapy. Moreover, it is necessary to monitor for potential side effects of the medications. Reflecting on the treatment course, the initial empirical antibiotic therapy targeting local inflammatory infection proved ineffective, and clinical improvement was only observed following the definitive identification of NTM. Subsequently, the selection of antibiotics tailored to the susceptibility test results led to a successful control of the disease. This underscores the crucial role of laboratory and etiological investigations in determining the pathogen and its drug sensitivity, which are vital for effective treatment. In clinical practice, non-healing wounds following conventional antibiotic therapy require careful evaluation. This is particularly important in patients with a history of invasive procedures or underlying immunodeficiency. In such cases, NTM infection should be strongly considered as a differential diagnosis. Additionally, reinforcing the management of underlying immune diseases is indispensable. Once NTM-induced skin or soft tissue infection is confirmed, a multifaceted approach combining antibiotic therapy with timely surgical debridement and management of infected tissues is essential to comprehensively curb disease progression and achieve favorable outcomes. Abbreviations SS Sjögren's Syndrome NTM Nontuberculous mycobacteria MABC Mycobacterium abscessus complex WGS whole genome sequencing MTB Mycobacterium tuberculosis Declarations Acknowledgements Not applicable. Authors’ contributions Tingjun Cao performed the literature review and drafted the initial manuscript. Ye Liu and Yuan Wang corrected the manuscript, and supplemented the framework, contents and important references of the article. Qianqian Bu and Jiayan Qian contributed to data collection and image preparation. Zihui Huang was responsible for the clinical management of the patient and contributed to the conception of the report. All authors reviewed the manuscript. All authors read and approve the final manuscript. Funding National Science Fund for Distinguished Young Scholars(82405398） Project of Nanjing University of Traditional Chinese Medicine Clinical Specialty Disease Research Institute (LCZBYJYZZ2024-008) Availability of data and materials Representative data (including selected lesion and radiological images, as well as summarized test results) have been included in the manuscript. The full datasets generated and/or analyzed during the current study are not publicly available due to patient confidentiality and institutional policies, but may be available from the corresponding author upon reasonable request and ethical approval. Ethics approval and consent to participate Informed consent was obtained from the patient to publish this case report in an online open-access publication. Patient had provided written consent to publish this case. Documentation is available upon request. All identifying information has been removed from the manuscript and fgures. Informed consent was obtained from the patient to publish this case report in an online open-access publication. Consent for publication Informed consent was obtained from the patient to publish this case report in an online open-access publication. Competing interests The authors declare no competing interests. References P B-Z, C B, H B, SJ B, R J, X M, K S, E T, A T, M R-C: Sjögren syndrome . Nature reviews Disease primers 2016, 2 :16047. International Journal of Nursing Education and Research . International Journal of Nursing Education and Research 2021. Shuo W, Zhendong Z, Qingjun W, Kai S, Xianghua M, Xiaopei Z: Chronic suppurative parotitis: a proposed classification . Chinese Medical Journal 1996. Knopf A, Pickhard A, Stark T, Schulz S, Scherer EQ: Recurrent abcesses of the parotid gland in Sjogren's syndrome . Hno 2009, 57 (9):959-963. Nie Q, Zhou Y, Chen H, Tao L, Chen N: Progress in epidemiological studies on non-tuberculous mycobacterial disease . Chinese Journal of Clinical Infectious Diseases 2020, 13 (5):394-400. Thomas HC, Lauren B, Joanna M, Alberto LGB, Harleen MSG, Anthony K, Elisa L, Ragini M, Durval R, Willy S et al : Typing and classification of non-tuberculous mycobacteria isolates . F1000Research 2020. Matt DJ, Jean-Louis H, Laurent K: Non-tuberculous mycobacteria and the rise of Mycobacterium abscessus . Nature Reviews Microbiology 2020. Alaa FB, Amr B, Athena P, Bhavik D, Arwa MF: Conservative Management of Chronic Suppurative Parotitis in Patients with Sjögren Syndrome: A Case Series . American Journal of Case Reports 2021. Yu C, Zheng L, Yang C, Shen N: Causes of chronic obstructive parotitis and management by sialoendoscopy . Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008, 105 (3):365-370. L M: Differentiating acute suppurative parotitis from acute exacerbation of a chronic parotitis: case reports . Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons 2008, 66 (9):1964-1968. J C, X H, Q M, T L, JH W, J X, Y L, H Z: Clinical Characteristics and Mortality of Non-tuberculous Mycobacterial Infection in Immunocompromised vs. Immunocompetent Hosts . Frontiers in medicine 2022, 9 :884446. S C, K B, S B, R W, MR L: The antimicrobial susceptibility of non-tuberculous mycobacteria . The Journal of infection 2016, 72 (3):324-331. SK S, V U: Epidemiology, diagnosis & treatment of non-tuberculous mycobacterial diseases . The Indian journal of medical research 2020, 152 (3):185-226. Ming‐Chun L, Pei‐Lun S, Tsu‐Lan W, Li-Hsin W, Cheng Y, Wen‐Hung C, An-Jing K, Tsui-Ping L, Jang‐Jih L, Cheng-Hsun C et al : Antimicrobial resistance in Mycobacterium abscessus complex isolated from patients with skin and soft tissue infections at a tertiary teaching hospital in Taiwan . Journal of Antimicrobial Chemotherapy 2017. A Y, K Y, T E: Refractory Infection of Mycobacterium abscessus : Skin and Soft Tissue Infection Recurred under Combination Therapy of Surgery and Outpatient Antibiotics . Journal of plastic and reconstructive surgery 2024, 3 (4):168-174. L V, A G, JL G, J R: Mycobacterium abscessus complex : A Review of Recent Developments in an Emerging Pathogen . Frontiers in cellular and infection microbiology 2021, 11 :659997. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 09 May, 2026 Reviewers agreed at journal 08 May, 2026 Reviewers agreed at journal 08 May, 2026 Reviews received at journal 01 Aug, 2025 Reviewers agreed at journal 31 Jul, 2025 Reviewers agreed at journal 22 Jul, 2025 Reviewers invited by journal 15 Jul, 2025 Editor invited by journal 17 Jun, 2025 Editor assigned by journal 15 Jun, 2025 Submission checks completed at journal 15 Jun, 2025 First submitted to journal 04 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6818387","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":485725197,"identity":"e78f871c-d260-4c13-8174-a8228a473f67","order_by":0,"name":"Tingjun Cao","email":"","orcid":"","institution":"Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine","correspondingAuthor":false,"prefix":"","firstName":"Tingjun","middleName":"","lastName":"Cao","suffix":""},{"id":485725198,"identity":"280fcf96-6412-4155-b1bc-c32caa81b73b","order_by":1,"name":"Qianqian 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2","display":"","copyAsset":false,"role":"figure","size":417051,"visible":true,"origin":"","legend":"\u003cp\u003ea.b.c.d. diffuse bilateral involvement with multiple abscesses in the left gland\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6818387/v1/cebb113948facf6ab4b51adf.png"},{"id":87318729,"identity":"47172c75-c9ad-4d7f-b44a-3c958902a28d","added_by":"auto","created_at":"2025-07-22 16:17:50","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":72959,"visible":true,"origin":"","legend":"\u003cp\u003eWeakly acid-fast colonies after 96-hour pus culture\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-6818387/v1/827027004854def957b48577.png"},{"id":87320343,"identity":"eb46e381-7271-4d69-87b6-a440b510d185","added_by":"auto","created_at":"2025-07-22 16:25:50","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":261357,"visible":true,"origin":"","legend":"\u003cp\u003ePathology No. 202401329\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-6818387/v1/a09dc2c7de733e07ef1c2dc2.png"},{"id":87320340,"identity":"46ea1bc9-bef3-45f3-958f-d3f6657494c1","added_by":"auto","created_at":"2025-07-22 16:25:50","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":42739,"visible":true,"origin":"","legend":"\u003cp\u003eswelling resolved\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-6818387/v1/f6f250d9156146cb37059aa9.png"},{"id":87321902,"identity":"7b15a9db-8580-4567-ac4d-68ce2791cf06","added_by":"auto","created_at":"2025-07-22 16:41:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1847404,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6818387/v1/d1f2ca10-1891-44f3-8d39-39c97b496c68.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Case Report: Suppurative Parotitis Secondary to Sjögren’s Syndrome Complicated by Nontuberculous Mycobacterial Infection","fulltext":[{"header":"Background","content":"\u003cp\u003eSS is a chronic autoimmune disorder that involves immune-mediated dysfunction of exocrine glands, with a focus on the salivary and lacrimal glands. It commonly results in the severe dryness of mucosal surfaces, principally in the mouth and eyes\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. Patients with SS often exhibit recurrent parotid swelling, commonly referred to as chronic recurrent parotitis or suppurative parotitis\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. Acute suppurative infections and severe systemic inflammatory reactions can occur in some patients\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e, but are rarely reported.\u003c/p\u003e\u003cp\u003eNTM are genera of mycobacteria other than Mycobacterium tuberculosis complex and Mycobacterium leprae, which are widely found in the environment such as water, soil, and air. They usually lead to chronic lung infections in patients with structural lung disease.Only a minority affecting extrapulmonary tissues, including Skin and Soft Tissue Infections (SSTI)\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. MABC is one of the fast-growing strains of NTM. Although rarely reported, it usually results to extrapulmonary infections, especially SSTI, usually manifest as papules, pustules, nodules, abscesses, seborrhea, folliculitis, or plaques. These lesions present with erythema and violaceous plaques frequently, typically without increased skin temperature. In advanced stages, the lesions may progress to skin ulcers\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. In recent years, with the widespread use of immunosuppressants and the improvements in pathogen diagnostic techniques, the detection rate of MABC infections in skin and soft tissues has gradually increased, warranting attention\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThis article reports a rare case of SS-secondary suppurative parotitis complicated by NTM (MABC) infection. After identifying the infection source and implementing targeted therapy, the patient achieved a favorable outcome.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eThe patient is a 44-year-old female diagnosed with SS in August 2018. She took hydroxychloroquine sulfate tablets intermittently and irregularly, and stopped taking the medication 6 months ago. Over the past six years, she experienced recurrent bilateral parotid gland swelling, and responded well to antibiotic therapy.\u003c/p\u003e\n\u003cp\u003eOn January 21, 2024, swelling and pain around the left ear occurred again. Despite multiple courses of conventional antibiotic treatment, no significant improvement was observed. On February 5, following saline irrigation of the left parotid duct, her symptoms worsened with marked swelling, palpable fluctuation and increased local skin temperature (Fig. 1). She was admitted to the hospital.\u003c/p\u003e\n\u003cp\u003ePhysical examination revealed a markedly enlarged left parotid gland, about 5×4 cm in size.The gland is hard as stone, with unclear boundaries and pronounced tenderness. The central skin exhibited a dark red discoloration, accompanied by palpable fluctuation and increased skin temperature. Additionally, there was a shallowening of the left nasolabial fold, deviation of the mouth corner, and restricted mouth opening to the extent of only one finger. Examination of the intraoral parotid duct orifice did not reveal the presence of pus.\u003c/p\u003e\n\u003cp\u003eOn admission, blood routine tests showed neutrophils 77.50% (normal range 40.00–75.00%), lymphocytes 14.40% (20.00–50.00%). Erythrocyte sedimentation rate was 55.00 mm/h (0.00–20.00 mm/h), rheumatoid factor was 226.99 IU/mL (0.00–20.00 IU/mL). Anti-SSA antibody was positive, while anti-SSB antibody was negative. PAS: negative. Liver and kidney function, electrolytes, procalcitonin, coagulation function, urinalysis, stool routine, and tests for syphilis and HIV antibodies showed no obvious abnormalities.\u003c/p\u003e\n\u003cp\u003eUltrasonography (Fig. 2:a.b.) and radiological imaging (Fig. 2:c.d.) showed diffuse lesions in both parotid glands with multiple abscess formations on the left sid. Under ultrasound guidance, pus was aspirated from the abscess area for culture. Pathogen examination showed positive for NTM (Fig. 3). Based on the results of drug sensitivity testing and NTM treatment guidelines, the patient was initiated on a combination therapy comprising clarithromycin 500mg twice daily, amikacin injection 0.8g once daily, and intravenous moxifloxacin 0.4g once daily.\u003c/p\u003e\n\u003cp\u003eAfter treatment, the lesion in the parotid gland localized, the local abscess ruptured. Consequently, a left parotid abscess incision and drainage procedure was performed, during which the necrotic tissue was debrided, and a small amount of pus was drained. The histopathological examination: epithelioid granulomas (Fig.\u0026nbsp;4, Pathology No. 202401329).\u003c/p\u003e\n\u003cp\u003eAfter continuing the original treatment regimen for 2 weeks, the wound healed, the parotid swelling completely resolved (Fig.\u0026nbsp;5), and the facial appearance returned to normal. The patient was discharged with instructions to continue the current treatment, take SS medications regularly, and follow up regularly.\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\n\n\n\n\n\n\n\n\n\n"},{"header":"Discussion and conclusions","content":"\u003cp\u003eSS is a chronic inflammatory auto-basic immune disease, which is mainly characterized by a decrease in saliva and tear secretion \u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. Reduced salivary flow can lead to stagnation within the long and narrow parotid ducts, increasing the risk of ductal obstruction. At the same time, reduced antimicrobial activity in saliva allows oral bacteria to more easily migrate retrogradely into the ducts. Therefore, SS often affects the parotid glands, leading to recurrent episodes of inflammation and swelling, termed chronic suppurative parotitis secondary to SS. Clinically, it often presents as repeated mild bilateral parotid swelling accompanied by mild pain, and usually without systemic manifestations\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eEarly administration of broad-spectrum antibiotics targeting Gram-positive cocci can effectively relieve the inflammatory response. Parotid duct perfusion is also a beneficial approach of treating chronic parotitis\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. By flushing the parotid gland with injectable drugs, the inflammatory purulent secretions can be discharged and their retention and absorption can be reduced. Besides, the direct delivery of therapeutic agents to the site of inflammation aids in controlling and relieving the condition\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn this case, the patient suffered from SS for 6 years and had repeated parotid gland enlargement, which always could be relieved by the conventional anti-infective treatment mentioned above. Before the onset of this time, the patient had stopped taking hydroxychloroquine sulfate tablets for 6 months, which may have caused an imbalance in the autoimmune function (anti-SSA antibody positive, anti-SSB antibody negative). So the immune system could not correctly recognize normal cells and tissues, resulting in damage to normal glands, which leads to glandular hypofunction, manifested as swollen glands and infections due to the retrograde movement of bacteria from the oral cavity\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. Consequently, the anti-infection treatment for the gland alone cannot solve the root cause of the immune disorder and glandular hypofunction, so the early anti-infection treatment has no obvious effect.\u003c/p\u003e\u003cp\u003eDuctal irrigation of the parotid gland is generally effective in managing chronic parotitis. However, during acute exacerbations, significant glandular edema and pain are often present, and performing intraductal irrigation at this stage may damage the parotid duct, potentially exacerbating glandular swelling and worsening the condition\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. In this case, the patient's swelling was worse after irrigation, and it was evident that the infection still existed and gradually involved the whole gland. It can be hypothesized that the inflammation was exacerbated due to the inappropriate perfusion in the acute phase. On the other hand, parotid ductal irrigation, as an invasive treatment, may also be a direct cause of the invasion of exogenous pathogens.\u003c/p\u003e\u003cp\u003eAt this point, observing the patient's parotid area under ultrasound, we found multiple microabscesses and subcutaneous abscess formation, confirming the presence of infection. In order to develop a rational and effective anti-infection program, it is essential to identify the pathogen to the strain level and perform drug sensitivity tests. In order to avoid further spreading of the inflammation by accidental injury to the parotid tissue during puncture and to ensure the accuracy of sampling, we took pus from the suppurating area of the lesion under the guidance of ultrasound for pathogenetic examination. And finally, we isolated NTM and identified them at the species level as an infection caused by the MABC.\u003c/p\u003e\u003cp\u003eNTM is ubiquitous in soil and water, posing as an opportunistic pathogen that frequently targets immunocompromised hosts\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. These microorganisms exhibit a high degree of antibiotic resistance, and there are notable differences in antibiotic susceptibility among different bacterial species\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. So further species identification is typically required to determine the optimal treatment strategy. Currently, DNA sequencing is the most accepted method for the identification and characterization of NTM species and subspecies, while whole genome sequencing (WGS) is considered the gold standard for species-level identification\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eMABC stands out as a prevalent cause of skin and soft tissue infections, particularly in association with foreign body implants and other invasive procedures\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e.The clinical manifestations of MABC infections closely resemble those caused by Mycobacterium tuberculosis (MTB), yet their treatment modalities differ significantly. Therefore, it is essential to exclude MTB and confirm NTM infection. Notably, MABC exhibits resistance to first-line anti-tuberculous drugs, necessitating the administration of macrolides (such as clarithromycin 500mg twice daily) in conjunction with one or more additional sensitive antibiotics for a minimum duration of 4 to 6 months\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. Additionally, surgical intervention, including incision and drainage of abscesses, is necessary to reduce bacterial load, alleviate local pressure, and facilitate wound healing by eliminating necrotic tissues and preventing bacterial dissemination\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn line with the susceptibility test results for the isolated MABC strain, the patient was prescribed clarithromycin 500mg orally twice daily, amikacin injection 0.8g daily, and moxifloxacin injection 0.4g intravenously daily. Once the abscess matured, local surgical debridement was performed to evacuate pus and necrotic tissue to reduced local pressure, eased swelling, and prevented bacterial proliferation and spread to surrounding tissues. The procedure also created a favorable environment for wound healing.\u003c/p\u003e\u003cp\u003eAfter maintaining this treatment regimen for two weeks, the patient discharged with complete wound healing and resolution of parotid gland swelling. She was instructed to continue medication until completion of the prescribed course to ensure adequate plasma drug concentrations, eradicating the pathogen, and minimizing the risk of developing drug resistance. The treatment regimen should be dynamically adjusted based on the antimicrobial susceptibility of the isolated pathogen during therapy. Moreover, it is necessary to monitor for potential side effects of the medications.\u003c/p\u003e\u003cp\u003eReflecting on the treatment course, the initial empirical antibiotic therapy targeting local inflammatory infection proved ineffective, and clinical improvement was only observed following the definitive identification of NTM. Subsequently, the selection of antibiotics tailored to the susceptibility test results led to a successful control of the disease. This underscores the crucial role of laboratory and etiological investigations in determining the pathogen and its drug sensitivity, which are vital for effective treatment. In clinical practice, non-healing wounds following conventional antibiotic therapy require careful evaluation. This is particularly important in patients with a history of invasive procedures or underlying immunodeficiency. In such cases, NTM infection should be strongly considered as a differential diagnosis. Additionally, reinforcing the management of underlying immune diseases is indispensable. Once NTM-induced skin or soft tissue infection is confirmed, a multifaceted approach combining antibiotic therapy with timely surgical debridement and management of infected tissues is essential to comprehensively curb disease progression and achieve favorable outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eSS Sj\u0026ouml;gren\u0026apos;s Syndrome\u003c/p\u003e\n\u003cp\u003eNTM Nontuberculous mycobacteria\u003cbr\u003e MABC Mycobacterium abscessus complex\u003c/p\u003e\n\u003cp\u003eWGS whole genome sequencing\u003c/p\u003e\n\u003cp\u003eMTB Mycobacterium tuberculosis\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003cbr\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003cbr\u003e \u003c/strong\u003eTingjun Cao performed the literature review and drafted the initial manuscript. Ye Liu and Yuan Wang corrected the manuscript, and supplemented the framework, contents and important references of the article. Qianqian Bu and Jiayan Qian contributed to data collection and image preparation. Zihui Huang was responsible for the clinical management of the patient and contributed to the conception of the report. All authors reviewed the manuscript. All authors read and approve the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003cbr\u003e \u003c/strong\u003eNational Science Fund for Distinguished Young Scholars(82405398）\u003c/p\u003e\n\u003cp\u003eProject of Nanjing University of Traditional Chinese Medicine Clinical Specialty Disease Research Institute (LCZBYJYZZ2024-008) \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003cbr\u003e \u003c/strong\u003eRepresentative data (including selected lesion and radiological images, as well as summarized test results) have been included in the manuscript. The full datasets generated and/or analyzed during the current study are not publicly available due to patient confidentiality and institutional policies, but may be available from the corresponding author upon reasonable request and ethical approval.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from the patient to publish this case report in an online open-access publication. Patient had provided written consent to publish this case. Documentation is available upon request. All identifying information has been removed from the manuscript and fgures. Informed consent was obtained from the patient to publish this case report in an online open-access publication. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from the patient to publish this case report in an online open-access publication. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eP B-Z, C B, H B, SJ B, R J, X M, K S, E T, A T, M R-C: \u003cstrong\u003eSj\u0026ouml;gren syndrome\u003c/strong\u003e. \u003cem\u003eNature reviews Disease primers \u003c/em\u003e2016, \u003cstrong\u003e2\u003c/strong\u003e:16047.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eInternational Journal of Nursing Education and Research\u003c/strong\u003e. \u003cem\u003eInternational Journal of Nursing Education and Research \u003c/em\u003e2021.\u003c/li\u003e\n\u003cli\u003eShuo W, Zhendong Z, Qingjun W, Kai S, Xianghua M, Xiaopei Z: \u003cstrong\u003eChronic suppurative parotitis: a proposed classification\u003c/strong\u003e. \u003cem\u003eChinese Medical Journal \u003c/em\u003e1996.\u003c/li\u003e\n\u003cli\u003eKnopf A, Pickhard A, Stark T, Schulz S, Scherer EQ: \u003cstrong\u003eRecurrent abcesses of the parotid gland in Sjogren\u0026apos;s syndrome\u003c/strong\u003e. \u003cem\u003eHno \u003c/em\u003e2009, \u003cstrong\u003e57\u003c/strong\u003e(9):959-963.\u003c/li\u003e\n\u003cli\u003eNie Q, Zhou Y, Chen H, Tao L, Chen N: \u003cstrong\u003eProgress in epidemiological studies on non-tuberculous mycobacterial disease\u003c/strong\u003e. \u003cem\u003eChinese Journal of Clinical Infectious Diseases \u003c/em\u003e2020, \u003cstrong\u003e13\u003c/strong\u003e(5):394-400.\u003c/li\u003e\n\u003cli\u003eThomas HC, Lauren B, Joanna M, Alberto LGB, Harleen MSG, Anthony K, Elisa L, Ragini M, Durval R, Willy S\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eTyping and classification of non-tuberculous mycobacteria isolates\u003c/strong\u003e. \u003cem\u003eF1000Research \u003c/em\u003e2020.\u003c/li\u003e\n\u003cli\u003eMatt DJ, Jean-Louis H, Laurent K: \u003cstrong\u003eNon-tuberculous mycobacteria and the rise of Mycobacterium abscessus\u003c/strong\u003e. \u003cem\u003eNature Reviews Microbiology \u003c/em\u003e2020.\u003c/li\u003e\n\u003cli\u003eAlaa FB, Amr B, Athena P, Bhavik D, Arwa MF: \u003cstrong\u003eConservative Management of Chronic Suppurative Parotitis in Patients with Sj\u0026ouml;gren Syndrome: A Case Series\u003c/strong\u003e. \u003cem\u003eAmerican Journal of Case Reports \u003c/em\u003e2021.\u003c/li\u003e\n\u003cli\u003eYu C, Zheng L, Yang C, Shen N: \u003cstrong\u003eCauses of chronic obstructive parotitis and management by sialoendoscopy\u003c/strong\u003e. \u003cem\u003eOral Surg Oral Med Oral Pathol Oral Radiol Endod \u003c/em\u003e2008, \u003cstrong\u003e105\u003c/strong\u003e(3):365-370.\u003c/li\u003e\n\u003cli\u003eL M: \u003cstrong\u003eDifferentiating acute suppurative parotitis from acute exacerbation of a chronic parotitis: case reports\u003c/strong\u003e. \u003cem\u003eJournal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons \u003c/em\u003e2008, \u003cstrong\u003e66\u003c/strong\u003e(9):1964-1968.\u003c/li\u003e\n\u003cli\u003eJ C, X H, Q M, T L, JH W, J X, Y L, H Z: \u003cstrong\u003eClinical Characteristics and Mortality of Non-tuberculous Mycobacterial Infection in Immunocompromised vs. Immunocompetent Hosts\u003c/strong\u003e. \u003cem\u003eFrontiers in medicine \u003c/em\u003e2022, \u003cstrong\u003e9\u003c/strong\u003e:884446.\u003c/li\u003e\n\u003cli\u003eS C, K B, S B, R W, MR L: \u003cstrong\u003eThe antimicrobial susceptibility of non-tuberculous mycobacteria\u003c/strong\u003e. \u003cem\u003eThe Journal of infection \u003c/em\u003e2016, \u003cstrong\u003e72\u003c/strong\u003e(3):324-331.\u003c/li\u003e\n\u003cli\u003eSK S, V U: \u003cstrong\u003eEpidemiology, diagnosis \u0026amp; treatment of non-tuberculous mycobacterial diseases\u003c/strong\u003e. \u003cem\u003eThe Indian journal of medical research \u003c/em\u003e2020, \u003cstrong\u003e152\u003c/strong\u003e(3):185-226.\u003c/li\u003e\n\u003cli\u003eMing‐Chun L, Pei‐Lun S, Tsu‐Lan W, Li-Hsin W, Cheng Y, Wen‐Hung C, An-Jing K, Tsui-Ping L, Jang‐Jih L, Cheng-Hsun C\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eAntimicrobial resistance in Mycobacterium abscessus complex isolated from patients with skin and soft tissue infections at a tertiary teaching hospital in Taiwan\u003c/strong\u003e. \u003cem\u003eJournal of Antimicrobial Chemotherapy \u003c/em\u003e2017.\u003c/li\u003e\n\u003cli\u003eA Y, K Y, T E: \u003cstrong\u003eRefractory Infection of Mycobacterium abscessus : Skin and Soft Tissue Infection Recurred under Combination Therapy of Surgery and Outpatient Antibiotics\u003c/strong\u003e. \u003cem\u003eJournal of plastic and reconstructive surgery \u003c/em\u003e2024, \u003cstrong\u003e3\u003c/strong\u003e(4):168-174.\u003c/li\u003e\n\u003cli\u003eL V, A G, JL G, J R: \u003cstrong\u003eMycobacterium abscessus complex : A Review of Recent Developments in an Emerging Pathogen\u003c/strong\u003e. \u003cem\u003eFrontiers in cellular and infection microbiology \u003c/em\u003e2021, \u003cstrong\u003e11\u003c/strong\u003e:659997.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Sjögren's Syndrome, Suppurative Parotitis, Nontuberculous Mycobacteria Infection, Mycobacterium Abscessus Complex, Parotid Duct Irrigation","lastPublishedDoi":"10.21203/rs.3.rs-6818387/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6818387/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e\u003cp\u003eSj\u0026ouml;gren\u0026rsquo;s Syndrome (SS) is a chronic autoimmune disease characterized by dysfunction of exocrine glands. Chronic recurrent parotitis is a common complication, but progression to suppurative parotitis, especially when caused by nontuberculous mycobacterial (NTM) infection, is rare and often misdiagnosed.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e\u003cp\u003eWe report a case of a 44-year-old woman with a 6-year history of SS who presented with left parotid swelling unresponsive to conventional antibiotics. Symptoms worsened after parotid duct irrigation. Imaging revealed multiple abscesses, and pus culture finally confirmed Mycobacterium abscessus complex (MABC). After receiving targeted antimicrobial therapy with clarithromycin, amikacin, and moxifloxacin, combined with surgical incision and drainage,the patient achieved complete recovery and was successfully discharged.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e\u003cp\u003eClinicians should consider NTM infection in SS patients with recurrent or treatment-resistant parotitis, especially after invasive procedures. Early microbial identification and drug sensitivity testing are essential to guide an appropriate therapy. Combined medical and surgical management can lead to favorable outcomes.\u003c/p\u003e","manuscriptTitle":"Case Report: Suppurative Parotitis Secondary to Sjögren’s Syndrome Complicated by Nontuberculous Mycobacterial Infection","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-22 16:17:45","doi":"10.21203/rs.3.rs-6818387/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-09T13:44:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"172921703535457719762910548803170935105","date":"2026-05-08T19:03:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"174125377592276993211829400194720235395","date":"2026-05-08T17:35:50+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-01T10:48:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"147947482178742351294260209782724078811","date":"2025-07-31T05:25:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"44186436614399300864159532806825673643","date":"2025-07-22T12:58:04+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-15T10:06:26+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-17T10:55:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-16T03:34:33+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-16T03:34:03+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Infectious Diseases","date":"2025-06-04T08:46:35+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f189e1ca-02bf-4057-9321-bec4dac1fae5","owner":[],"postedDate":"July 22nd, 2025","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-09T13:44:53+00:00","index":97,"fulltext":""},{"type":"reviewerAgreed","content":"172921703535457719762910548803170935105","date":"2026-05-08T19:03:16+00:00","index":96,"fulltext":""},{"type":"reviewerAgreed","content":"174125377592276993211829400194720235395","date":"2026-05-08T17:35:50+00:00","index":95,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-07-22T16:17:45+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-22 16:17:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6818387","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6818387","identity":"rs-6818387","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}