A rare duo: bacterial parotitis and CMV in a neonate – Case report and diagnostic challenges

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The main risk factors include dehydration, prematurity and immunodeficiency. Clinical manifestations commonly involve swelling, tenderness and purulent discharge. Management generally consists of intravenous antibiotics with surgical intervention reserved for complications. Ultrasound plays a critical role in diagnosis and management of the disease, especially when there is no purulent material from Stensen's duct available for analysis. Early recognition and appropriate treatment are crucial for preventing severe outcomes in these cases. CASE REPORT We report a case of a 7-day-old full-term, breastfed girl admitted with right preauricular swelling and poor feeding. Born without complications, her symptoms also included irritability and purulent discharge from the right Stensen’s duct. Lab tests showed elevated white blood cells and neutrophilia, and ultrasound confirmed an enlarged right parotid gland with an abscess. Empirical antibiotics, clindamycin and cefotaxime, were initiated. Cultures identified Staphylococcus aureus in both the Stensen’s duct discharge and the mother’s milk. Antibiotics were adjusted to clindamycin and later cefaclor. Further investigations for congenital infections through brain ultrasound revealed cysts and vascular abnormalities, and CMV was diagnosed from urine and salivary samples, despite maternal immunity. The patient responded well to antibiotics, showing reduced swelling and normal feeding. She was discharged after 10 days, fully recovered, with follow-up for CMV ongoing. CONCLUSION In neonates with acute parotitis, especially with neurological signs, CMV should be considered due to its multiorgan involvement and link to immunodeficiency. Adequate imaging and laboratory studies are crucial for early diagnosis, guiding treatment and preventing long-term complications. case report Neonatal parotitis Concurrent bacterial and viral infections in newborns Congenital cytomegalovirus (CMV) infection ultrasound in newborns Figures Figure 1 Figure 2 Figure 3 INTRODUCTION Neonatal salivary gland infections represent a rare condition and they mainly affect parotid gland, which seems to be the preferred site for this infection due to its exclusively production of serous secretions without the bacteriostatic properties of the mucoid component [ 1 ], with secretory stasis and secondary bacterial superinfection, typically caused by Staphylococcus aureus and Streptococcus species [ 2 – 5 ]. The main risk factors include dehydration, prematurity and immunodeficiency. Clinically, these infections are characterized by swelling, tenderness, pain and purulent discharge from Stensen’s duct. Intravenous antibiotics are the mainstay of treatment, while the need for surgical intervention is reservedfor complications, such as organized abscesses or refractory cases [ 6 ]. Cytomegalovirus (CMV) infection commonly involves salivary gland ,especially in congenital and immunocompromised individuals, potentially increasing susceptibility to bacterial infections, including bacterial parotitis, due to salivary stasis [ 7 ]. Ultrasound is pivotal in diagnosing and managing parotid lesions in children, both for differentiating between other pathological conditions and monitoring treatment response, especially when culture samples are unavailable [ 8 ]. This case report details a 7-day-old full-term female, born from an uncomplicated pregnancy, who presented with right preauricular swelling, tenderness and poor feeding and was diagnosed with acute bacterial parotitis complicated by abscess formation. Although maternal immunity to CMV during pregnancy, postnatal investigations guided by the infant's parotitis severe and early presentation with also poor feeding, following abnormal cerebral ultrasound findings, led to the diagnosis of congenital CMV infection. Ultrasound proved thus crucial for both diagnosing parotitis and identifying systemic CMV involvement. To our knowledge, this is the first documented case of neonatal parotitis with concurrent CMV infection diagnosed postnatally in an otherwise uncomplicated pregnancy, corroborated by radiological findings. NARRATIVE A 7-day-old, full-term, breastfed female was admitted to our hospital with right preauricular swelling and poor feeding, both starting that same day. She was born at 37 + 5 weeks of gestation via uncomplicated eutocic delivery, with a birth weight of 2950g and normal anthropometric measures according to INeS Italian charts [ 9 ]. The mother’s Group B Streptococcus (GBS) screening was negative. On clinical examination, the infant was afebrile but exhibited poor sucking despite normal reactivity and muscle tone. The right preauricular and parotid region appeared erythematous, warm, swallen and apparently painful on palpation. Oral cavity examination revealed purulent discharge from the right Stensen’s duct. Laboratory tests revealed a white blood cell count of 14.1 × 10⁹/L with neutrophilia (neutrophils: 58.8%, 8310/L), while C-reactive protein (CRP) was elevated at 1.5 mg/dL (normal < 0.50 mg/dL). Ultrasound examination of the right parotid and preauricular region showed an increased vascularity with abscess collection observed in the lower third of the gland [Figure 1 ]. Based on clinical presentation and ultrasound findings, the baby was diagnosed with right acute parotitis, so a swab of the purulent discharge was sent for microbiological analysis and empiric antibiotic therapy with intravenous clindamycin and cefotaxime was started. The culture of the Stensen’s duct exudate tested positive for Staphylococcus aureus, sensitive to the prescribed antibiotics on the antibiogram. Therapy was then converted to intravenous clindamycin for 7 days, followed then by oral cefaclor. Diagnostic testing of the mother’s breast milk revealed presence of Staphylococcus aureus with the same resistance profile, prompting maternal treatment with oral amoxicillin-clavulanic acid. Three days after admission concerns about potential congenital infections contributing to the symptoms arose, particularly due to the newborn’s poor feeding and irritability. Awaiting the results of the culture tests, a cerebral ultrasound was performed to screen for neurological and systemic involvement and showed a monolocular germinolytic cyst in the germinal matrix of the right lateral ventricle and a multilocular cyst at the caudate-thalamic sulcus of the left ventricle, associated with bilateral hyperechogenicity of the lenticulostriate vessels [Figure 2 ]. Despite the mother’s documented immunity to cytomegalovirus (CMV; IgM negative, IgG positive) in the first trimester, CMV DNA testing of the newborn’s urine and saliva was performed. Both tests were positive for CMV DNA (> 250,000,000 copies/ml in the salivary sample and 10,523,729 copies/ml in the urine sample). Given this, hearing tests, initially normal on the second day of life were repeated and remained normal. The newborn’s condition improved during her hospital stay, with resumption of normal feeding and weight gain. A favorable clinical response to antibiotic therapy was observed, with a notable reduction in the parotid region swelling. She was discharged after 10 days, fully recovered, with a follow-up ultrasound showing normal results, only showing a slight hypoechoic inhomogeneity on the site of the previous abscess [Figure 3 ]. A cerebral MRI was scheduled to further investigate for potential CMV involvement. DISCUSSION Neonatal and pediatric parotid masses represent a rare condition and can they arise from many pathological situations [ 10 ]. Among theese, acute bacterial parotitis has a prevalence of 3.8–14 cases per 10,000 neonatal admissions [ 5 ], but facial swelling in neonates can result from a range of conditions like viral or bacterial infections [ 11 ], either skin infections, lymphadenopathy, vascular or lymphatic lesions, and tumors [ 12 ]. Clinically, acute parotitis is diagnosed based on swelling of the parotid gland, purulent discharge from Stensen’s duct, and afterwards pathogen identification from pus culture. However, in cases without purulent discharge or negative culture results, ultrasound can confirm the diagnosis by revealing typical features such as an enlarged, edematous and hypervascular parotid gland with hypoechoic areas [ 13 ]. Transmission of bacteria during breastfeeding or through contaminated formula can be a potential cause of sialadenitis [ 14 ], consistently with our case report in which mother’s milk tested positive for Staphylococcus aureus, with the same resistance profile of the infant's culture. Staphylococcus species, including MRSA, are not typically transmitted through breast milk but they can be transferred through direct contact with infected tissue, such as an open lesion on the breast, or expressed milk contaminated with such tissue [ 15 ]. Given the potential infectivity of breastfeeding and the newborn's poorfeeding during the initial phase of hospitalization, the baby was temporarily fed via nasogastric tube to ensure adequate nutrition. Once the infection was controlled, breastfeeding was safely resumed. Ultrasound remains the preferred initial imaging modality in case of suspected neonatal parotitis: its non-invasive nature, absence of ionizing radiation and ability to show real-time glandular involvement and abscess formation make it an invaluable diagnostic tool [ 16 ]. This imaging method also helps distinguish parotitis from other reasons for neonatal facial swelling, like swallen lymphnode or submandibular infections and, last but not least, it's useful for spotting anatomical abnormalities, salivary duct obstructions or neoplasms too [ 12 , 17 ]. We're reporting a rare case of neonatal parotitis in a 7-day-old female neonate, complicated by a concurrent diagnosis of congenital CMV infection, evidenced by cerebral ultrasound and MRI findings. To the best of the author’s knowledge, there's only been one other similar case in medical literature regarding neonatal parotitis with coexisting congenital CMV infection - a newborn whose mother took methyldopa while pregnant and tested positive for CMV IgM in early gestation[ 18 ]. CMV is a common congenital infection associated with potential long-term sequelae, including neurological deficits, as a leading cause of permanent neurological disabilities and cognitive disabilities in childhood. Although rare, CMV involvement of the salivary glands has been documented in both congenital and acquired infections [ 19 ]. In the case documented by Todoroki et al., Staphylococcus aureus was identified as the causative agent but it was hypothesized that CMV-induced salivary stasis and immune alterations may predispose to bacterial parotitis through mechanisms such as salivary stasis, promoting bacterial ascent in the salivary ducts, particularly in the presence of dehydratation [ 18 ]. Greenberg's team suggested a link between CMV presence in saliva and salivary gland dysfunction including xerostomia, particularly in HIV-infected patients [ 7 ]. In immunocompromised patients, such as those with HIV, CMV co-infection may further weaken the immune response, making them more susceptible to opportunistic bacterial infections, including parotitis [ 19 ]. Similar to other physiological systems, the immune defense is not fully developed at birth, resulting in an increased susceptibility to infections [ 20 ]. In those patients, coexisting infections could compromise glandular defenses, making the environment more favorable for bacterial colonization. Todoroki et al. hypothesized that, although Staphylococcus aureus was the causative agent of parotitis (the most isolated organism in bacterial parotitis), CMV-induced salivary stasis promoting bacterial ascent along the salivary duct, together with immune system alterations may predispose newborns to bacterial parotitis, particularly in the presence of dehydration. Early-life cranial ultrasound is crucial for newborns with potential congenital infections, as literature has revealed a strong correlation between cerebral US abnormalities and the prediction of outcome in newborns who were congenitally infected with CMV [ 21 ]. Although a direct correlation between neonatal bacterial parotitis and congenital CMV infection is yet to be established, clinicians should keep CMV infection in mind when treating neonatal parotitis, especially when neurological symptoms appear. Congenital CMV can severely impact multiple body systems. Therefore, screening newborns at risk, especially those showing unusual cranial ultrasound results, is essential as early diagnosis and antiviral treatment can be crucial in mitigating the neurological and systemic effects of CMV infection. CONCLUSION This case enlights the rarity of neonatal parotitis and the importance of a multidimensional diagnostic approach including ultrasound and laboratory testing to detect coexisting systemic infections such as congenital CMV, which could impact the course and management of a coexisting sistemyc infection. Ultrasound is recommended as a screening tool for early detection of glandular involvement in neonates at high risk for parotiditis, particularly those with immune deficiencies or dehydration. Its ability to identify characteristic glandular changes, assess systemic involvement, guide further diagnostics and monitor treatment is crucial for providing prompt and effective care. When neonatal parotitis occurs, especially with neurological signs or symptoms, CMV should be included in the differential diagnosis, given the virus' role in multiorgan involvement, including the parotid gland, and its association with immunodeficiency. A comprehensive evaluation with imaging and laboratory studies is essential for timely identification and effective management of CMV infection. This strategy aims to prevent or, at least, mitigate long-term complications such as neurodevelopmental impairment. The coexistence of neonatal parotitis and congenital CMV infection presents diagnostic and therapeutic challenges, emphasizing the importance of thorough investigation in such cases. Declarations Ethics approval and consent to participate This case report has been writed according with the ethical standards of our institution. An informed verbal consent was obtained from the patient's parents for the diagnostic procedures and treatment described in this report. Consent for publication Oral informed consent was obtained from the patient's parents for the publication of this case report and accompanying images. If a written consent is necessary for the Editor-inChief of this journal, please let us know and we’ll provide it as soon as possible. Availability of data and material The data used and analyzed during the current study are available from the corresponding author on reasonable request, subject to privacy and ethical restrictions. Competing interests The authors declare that they have no competing interests related to this case report. Funding This case report received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Authors' contributions EP: Conceptualization, data collection, wrote the initial draft and revised the manuscript. MC: Data analysis, literature review, and manuscript revision. Both authors read and approved the final manuscript. EM: Provided and described parotid ultrasound images. The author read and approved the final manuscript. MC: Provided and described cranial ultrasound images. The author read and approved the final manuscript. Acknowledgements The authors would like to thank the nursing and medical staff of the neonatal intensive care unit of Carlo Pizzardi Maggiore Hospital of Bologna. We also express our gratitude to the Elena Mengozzi MD of the radiology Department for her assistance with the ultrasound examinations and interpretations. Special thanks to Matilde Maria Ciccia MD for her review of the neurological findings, and for Mariasole Conte MD for her expert review of the manuscript. References El Omri M, Jemli S, Belakhdher M, Kermani W. Neonatal Suppurative Parotitis: Case Report and Review of Literature. Ear Nose Throat J. 2024 Mar 13:1455613241234281. 10.1177/01455613241234281 . Epub ahead of print. PMID: 38476055. Makhoul J, Lorrot M, Teissier N, Delacroix G, Doit C, Bingen E. al. Acute bacterial parotitis in infants under 3 months of age: a retrospective study in a pediatric tertiary care center. Arch Pediatr 2011; 181284–128. Özdemir H, Karbuz A, Ciftçi E, Fitöz S, Ince E, Dogru U. Acute neonatal suppurative parotitis: a case report and review of the literature. Int J Infect Dis 2011; e15500–50. Ayala Curiel J. Galán del Río P,Poza delVal C,Aguirre CondeA, Cotero Lavin A. Neonatal acute suppurative parotitis. Pediatr (Barc) 2004; 60274–277. Acute parotitis in. a newborn: a case report and review of the literature Liliana Costa, Laurentino M. Leal, Fernando Vales, Margarida Santos. Egypt J Otolaryngol. 2016;32:236–9. Decembrino L, Ruffinazzi G, Russo F, Manzoni P, Stronati M. Monolateral suppurative parotitis in a neonate and review of literature. Int J Pediatr Otorhinolaryngol 2012; 76930–933. Greenberg MS, Glick M, Nghiem L, Stewart JCB, Hodinka R, Dubin G. Relationship of cytomegalovirus to salivary gland dysfunction in HIV-infected patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1997. Role of high. resolution ultrasound in parotid lesions in children. Kushaljit Singh Sodhi *, Murray Bartlett, Nirmal Kumar Prabhu - Department of Medical Imaging, Royal Children’s Hospital, Flemington Road, Parkville, Melbourne, Victoria 3052, Australia. Valutazione Antropometrica neonatale. Riferimento carte INeS. http://www.inescharts.com Orvidas LJ, Kasperbauer JL, Lewis JE, Olsen KD, Lesnick TG. Pediatric parotid masses. Arch Otolaryngol Head Neck Surg 2000; 126177–184. Garcia CJ, Flores PA, Arce JD, Chuaqui B, Schwartz DS. Ultrasonography in the study of salivary gland lesions in children. Pediatr Radiol. 1998;28:418–25. Makhoul J, Lorrot M, Teissier N, Delacroix G, Doit C, Bingen E. al. Acute bacterial parotitis in infants under 3 months of age: a retrospective study in a pediatric tertiary care center. Arch Pediatr 2011. Neonatal Parotitis. A Case Report and Review of the LiteratureJulie Pollenus, MD,* and Stefaan Van Lierde, MD, PhD. Tapısız A, Belet N, C¸iftc¸i E, Fito¨z S. I ˙nce E, Dog˘ru U¨. Neonatal suppurative submandibular sialadenitis. Turk J Pediatr. 2009;51:180–2. Academy of Breastfeeding Medicine Clinical Protocol #36. The Mastitis Spectrum, Revised 2022 Katrina B. Mitchell,1 Helen M. Johnson,2 Juan Miguel Rodrı´guez,3 Anne Eglash,4 Charlotte Scherzinger,5 Irena Zakarija-Grkovic,6 Kyle Widmer Cash,7 Pamela Berens,8 Brooke Miller,9 and the Academy of Breastfeeding Medicine]. Cristiµn J, Flores JosØ DA. Benedicto Chuaqui Dana S. Schwartz Ultrasonography in the study of salivary gland lesions in children, Pediatric Radiology. Decembrino L, Ruffinazzi G, Russo F, Manzoni P, Stronati M. Monolateral suppurative parotitis in a neonate and review of literature. Int J Pediatr Otorhinolaryngol 2012; 76930–933. Neonatal suppurative parotitis possibly associated with congenital cytomegalovirus infection. and maternal methyldopa administration Yukiko Todoroki, 1 Hirokazu Tsukahara, 1 Masao Kawatani, 1 Yusei Ohshima, 1 Ken-Ichi Shukunami, 2 Fumikazu Kotsuji 2 And Mitsufumi Mayumi 1 Departments of 1 Pediatrics and 2 Obstetrics and Gynecology, Faculty of Medical Sciences, University of Fukui, Fukui, Japan. Variend S, O’Neill D, Arnold P. The possible significance of cytomegaloviral parotitis in infant and early childhood deaths. Arch Pathol Lab Med. 1997;121:1272–6. Neonatal I. John Tregoning, Imperial College London, UK, British Society for Immunology. Cranial ultrasound in congenital cytomegalovirus infection. Lidija Banjac*, Gorica Banjac Department of Neonatology, Clinical Center of Montenegro, Podgorica, Montenegro; Cranial Ultrasound Scanning and Prediction of Outcome in Newborns with Congenital Cytomegalovirus Infection Gina Ancora,Marcello Lanari. J Pediatr, 2007. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major revision 09 Nov, 2024 Reviewers agreed at journal 05 Nov, 2024 Reviewers invited by journal 05 Nov, 2024 Editor assigned by journal 30 Oct, 2024 First submitted to journal 23 Oct, 2024 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. 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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-5306904","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":374326535,"identity":"87a84205-200a-425e-9d13-250b947a7fff","order_by":0,"name":"Enrico Perre","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3ElEQVRIiWNgGAWjYJCCA1Ca8QGQ4OEjRQuzAUgLGym2sUmASULK+KV7Hx74UXFHznz24WOVX3PsZNgYmB8+uoFHi+Sc4wYHe848M5Y5l5Z2W3ZbMtBhbMbGOXi0GNxIYzjM2HY4cQYPj9ltyW3MQC08bNL4tNhDtdTP4OH/Viy5rZ6wFgMJiJYECR4eNsaP2w4T1iIBtAXkF8MZPGzG0ozbjvOwMRPwC/+MNOYPwBCTl+Bhfvjx57Zqe3725oeP8WmBggNgkpkHTBJWjtDC+IM41aNgFIyCUTDCAAAYIEQS9IQfsQAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0002-0663-9994","institution":"Ospedale Maggiore Carlo Alberto Pizzardi","correspondingAuthor":true,"prefix":"","firstName":"Enrico","middleName":"","lastName":"Perre","suffix":""},{"id":374326536,"identity":"440b6ca5-3252-48a4-a161-48331bfdb4d7","order_by":1,"name":"Mariasole Conte","email":"","orcid":"","institution":"Maggiore Hospital Carlo Alberto Pizzardi: Ospedale Maggiore Carlo Alberto Pizzardi","correspondingAuthor":false,"prefix":"","firstName":"Mariasole","middleName":"","lastName":"Conte","suffix":""},{"id":374326537,"identity":"0c78b31a-db7f-40d4-8b91-63c56d0bacfb","order_by":2,"name":"Elena Mengozzi","email":"","orcid":"","institution":"Maggiore Hospital Carlo Alberto Pizzardi: Ospedale Maggiore Carlo Alberto Pizzardi","correspondingAuthor":false,"prefix":"","firstName":"Elena","middleName":"","lastName":"Mengozzi","suffix":""},{"id":374326538,"identity":"ffe4db50-abe4-48dd-b9b8-974d507e1bcf","order_by":3,"name":"Matilde Maria Ciccia","email":"","orcid":"","institution":"Maggiore Hospital Carlo Alberto Pizzardi: Ospedale Maggiore Carlo Alberto Pizzardi","correspondingAuthor":false,"prefix":"","firstName":"Matilde","middleName":"Maria","lastName":"Ciccia","suffix":""}],"badges":[],"createdAt":"2024-10-21 20:33:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5306904/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5306904/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":71051889,"identity":"208d9f4b-a5ce-4892-85b7-5d121598e0cb","added_by":"auto","created_at":"2024-12-10 15:51:27","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":403168,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eParotid Ultrasound - A hypoechoic area measuring approximately 2.3 cm in maximum diameter is highlighted in the lower third of the right parotid. The lesion shows peripheral vascularization, suggesting the presence of an abscess.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-5306904/v1/bdf9fdb2f101f9a9fc84b697.png"},{"id":71051473,"identity":"f9f7534c-afa0-4363-b1ce-d004a6f89703","added_by":"auto","created_at":"2024-12-10 15:43:27","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":354871,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eTransfontanellar brain ultrasound performed using an 8-5 MHz convex probe through the bregmatic fontanelle - In the left parasagittal view, a multilocular cyst is visible at the level of the caudate-thalamic sulcus within the left ventricle.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5306904/v1/2e019c5c5cabdaa58796046f.jpeg"},{"id":71051472,"identity":"ec30abb3-c80e-4b84-897f-4a5d1517b913","added_by":"auto","created_at":"2024-12-10 15:43:27","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":399502,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eParotid ultrasound performed after hospital discharge - At the second check-up there is no longer a hypoechoic abscess collection in the parotid gland, while a mild hypoechoic inhomogeneity remains at the site of the previous abscess.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5306904/v1/b6e7d2fe3c302e9002b82903.jpeg"},{"id":71052115,"identity":"eec5f7fa-92a3-4901-b6f9-e9e6d22da39f","added_by":"auto","created_at":"2024-12-10 15:51:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1403138,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5306904/v1/e2262502-cbaa-449e-b21f-735e64b75379.pdf"}],"financialInterests":"","formattedTitle":"A rare duo: bacterial parotitis and CMV in a neonate – Case report and diagnostic challenges","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eNeonatal salivary gland infections represent a rare condition and they mainly affect parotid gland, which seems to be the preferred site for this infection due to its exclusively production of serous secretions without the bacteriostatic properties of the mucoid component [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], with secretory stasis and secondary bacterial superinfection, typically caused by Staphylococcus aureus and Streptococcus species [\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The main risk factors include dehydration, prematurity and immunodeficiency. Clinically, these infections are characterized by swelling, tenderness, pain and purulent discharge from Stensen\u0026rsquo;s duct. Intravenous antibiotics are the mainstay of treatment, while the need for surgical intervention is reservedfor complications, such as organized abscesses or refractory cases [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCytomegalovirus (CMV) infection commonly involves salivary gland ,especially in congenital and immunocompromised individuals, potentially increasing susceptibility to bacterial infections, including bacterial parotitis, due to salivary stasis [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUltrasound is pivotal in diagnosing and managing parotid lesions in children, both for differentiating between other pathological conditions and monitoring treatment response, especially when culture samples are unavailable [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. This case report details a 7-day-old full-term female, born from an uncomplicated pregnancy, who presented with right preauricular swelling, tenderness and poor feeding and was diagnosed with acute bacterial parotitis complicated by abscess formation.\u003c/p\u003e \u003cp\u003eAlthough maternal immunity to CMV during pregnancy, postnatal investigations guided by the infant's parotitis severe and early presentation with also poor feeding, following abnormal cerebral ultrasound findings, led to the diagnosis of congenital CMV infection. Ultrasound proved thus crucial for both diagnosing parotitis and identifying systemic CMV involvement.\u003c/p\u003e \u003cp\u003eTo our knowledge, this is the first documented case of neonatal parotitis with concurrent CMV infection diagnosed postnatally in an otherwise uncomplicated pregnancy, corroborated by radiological findings.\u003c/p\u003e"},{"header":"NARRATIVE","content":"\u003cp\u003eA 7-day-old, full-term, breastfed female was admitted to our hospital with right preauricular swelling and poor feeding, both starting that same day. She was born at 37\u0026thinsp;+\u0026thinsp;5 weeks of gestation via uncomplicated eutocic delivery, with a birth weight of 2950g and normal anthropometric measures according to INeS Italian charts [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The mother\u0026rsquo;s Group B Streptococcus (GBS) screening was negative.\u003c/p\u003e \u003cp\u003eOn clinical examination, the infant was afebrile but exhibited poor sucking despite normal reactivity and muscle tone. The right preauricular and parotid region appeared erythematous, warm, swallen and apparently painful on palpation. Oral cavity examination revealed purulent discharge from the right Stensen\u0026rsquo;s duct.\u003c/p\u003e \u003cp\u003eLaboratory tests revealed a white blood cell count of 14.1 \u0026times; 10⁹/L with neutrophilia (neutrophils: 58.8%, 8310/L), while C-reactive protein (CRP) was elevated at 1.5 mg/dL (normal\u0026thinsp;\u0026lt;\u0026thinsp;0.50 mg/dL). Ultrasound examination of the right parotid and preauricular region showed an increased vascularity with abscess collection observed in the lower third of the gland [Figure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e]. Based on clinical presentation and ultrasound findings, the baby was diagnosed with right acute parotitis, so a swab of the purulent discharge was sent for microbiological analysis and empiric antibiotic therapy with intravenous clindamycin and cefotaxime was started.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe culture of the Stensen\u0026rsquo;s duct exudate tested positive for Staphylococcus aureus, sensitive to the prescribed antibiotics on the antibiogram. Therapy was then converted to intravenous clindamycin for 7 days, followed then by oral cefaclor.\u003c/p\u003e \u003cp\u003eDiagnostic testing of the mother\u0026rsquo;s breast milk revealed presence of Staphylococcus aureus with the same resistance profile, prompting maternal treatment with oral amoxicillin-clavulanic acid.\u003c/p\u003e \u003cp\u003eThree days after admission concerns about potential congenital infections contributing to the symptoms arose, particularly due to the newborn\u0026rsquo;s poor feeding and irritability. Awaiting the results of the culture tests, a cerebral ultrasound was performed to screen for neurological and systemic involvement and showed a monolocular germinolytic cyst in the germinal matrix of the right lateral ventricle and a multilocular cyst at the caudate-thalamic sulcus of the left ventricle, associated with bilateral hyperechogenicity of the lenticulostriate vessels [Figure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eDespite the mother\u0026rsquo;s documented immunity to cytomegalovirus (CMV; IgM negative, IgG positive) in the first trimester, CMV DNA testing of the newborn\u0026rsquo;s urine and saliva was performed. Both tests were positive for CMV DNA (\u0026gt;\u0026thinsp;250,000,000 copies/ml in the salivary sample and 10,523,729 copies/ml in the urine sample). Given this, hearing tests, initially normal on the second day of life were repeated and remained normal.\u003c/p\u003e \u003cp\u003eThe newborn\u0026rsquo;s condition improved during her hospital stay, with resumption of normal feeding and weight gain. A favorable clinical response to antibiotic therapy was observed, with a notable reduction in the parotid region swelling. She was discharged after 10 days, fully recovered, with a follow-up ultrasound showing normal results, only showing a slight hypoechoic inhomogeneity on the site of the previous abscess [Figure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e]. A cerebral MRI was scheduled to further investigate for potential CMV involvement.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eNeonatal and pediatric parotid masses represent a rare condition and can they arise from many pathological situations [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Among theese, acute bacterial parotitis has a prevalence of 3.8\u0026ndash;14 cases per 10,000 neonatal admissions [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], but facial swelling in neonates can result from a range of conditions like viral or bacterial infections [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], either skin infections, lymphadenopathy, vascular or lymphatic lesions, and tumors [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Clinically, acute parotitis is diagnosed based on swelling of the parotid gland, purulent discharge from Stensen\u0026rsquo;s duct, and afterwards pathogen identification from pus culture. However, in cases without purulent discharge or negative culture results, ultrasound can confirm the diagnosis by revealing typical features such as an enlarged, edematous and hypervascular parotid gland with hypoechoic areas [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTransmission of bacteria during breastfeeding or through contaminated formula can be a potential cause of sialadenitis [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], consistently with our case report in which mother\u0026rsquo;s milk tested positive for Staphylococcus aureus, with the same resistance profile of the infant's culture. Staphylococcus species, including MRSA, are not typically transmitted through breast milk but they can be transferred through direct contact with infected tissue, such as an open lesion on the breast, or expressed milk contaminated with such tissue [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Given the potential infectivity of breastfeeding and the newborn's poorfeeding during the initial phase of hospitalization, the baby was temporarily fed via nasogastric tube to ensure adequate nutrition. Once the infection was controlled, breastfeeding was safely resumed.\u003c/p\u003e \u003cp\u003eUltrasound remains the preferred initial imaging modality in case of suspected neonatal parotitis: its non-invasive nature, absence of ionizing radiation and ability to show real-time glandular involvement and abscess formation make it an invaluable diagnostic tool [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis imaging method also helps distinguish parotitis from other reasons for neonatal facial swelling, like swallen lymphnode or submandibular infections and, last but not least, it's useful for spotting anatomical abnormalities, salivary duct obstructions or neoplasms too [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe're reporting a rare case of neonatal parotitis in a 7-day-old female neonate, complicated by a concurrent diagnosis of congenital CMV infection, evidenced by cerebral ultrasound and MRI findings. To the best of the author\u0026rsquo;s knowledge, there's only been one other similar case in medical literature regarding neonatal parotitis with coexisting congenital CMV infection - a newborn whose mother took methyldopa while pregnant and tested positive for CMV IgM in early gestation[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCMV is a common congenital infection associated with potential long-term sequelae, including neurological deficits, as a leading cause of permanent neurological disabilities and cognitive disabilities in childhood. Although rare, CMV involvement of the salivary glands has been documented in both congenital and acquired infections [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In the case documented by Todoroki et al., Staphylococcus aureus was identified as the causative agent but it was hypothesized that CMV-induced salivary stasis and immune alterations may predispose to bacterial parotitis through mechanisms such as salivary stasis, promoting bacterial ascent in the salivary ducts, particularly in the presence of dehydratation [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGreenberg's team suggested a link between CMV presence in saliva and salivary gland dysfunction including xerostomia, particularly in HIV-infected patients [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In immunocompromised patients, such as those with HIV, CMV co-infection may further weaken the immune response, making them more susceptible to opportunistic bacterial infections, including parotitis [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSimilar to other physiological systems, the immune defense is not fully developed at birth, resulting in an increased susceptibility to infections [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn those patients, coexisting infections could compromise glandular defenses, making the environment more favorable for bacterial colonization.\u003c/p\u003e \u003cp\u003eTodoroki et al. hypothesized that, although Staphylococcus aureus was the causative agent of parotitis (the most isolated organism in bacterial parotitis), CMV-induced salivary stasis promoting bacterial ascent along the salivary duct, together with immune system alterations may predispose newborns to bacterial parotitis, particularly in the presence of dehydration. Early-life cranial ultrasound is crucial for newborns with potential congenital infections, as literature has revealed a strong correlation between cerebral US abnormalities and the prediction of outcome in newborns who were congenitally infected with CMV [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Although a direct correlation between neonatal bacterial parotitis and congenital CMV infection is yet to be established, clinicians should keep CMV infection in mind when treating neonatal parotitis, especially when neurological symptoms appear.\u003c/p\u003e \u003cp\u003eCongenital CMV can severely impact multiple body systems. Therefore, screening newborns at risk, especially those showing unusual cranial ultrasound results, is essential as early diagnosis and antiviral treatment can be crucial in mitigating the neurological and systemic effects of CMV infection.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis case enlights the rarity of neonatal parotitis and the importance of a multidimensional diagnostic approach including ultrasound and laboratory testing to detect coexisting systemic infections such as congenital CMV, which could impact the course and management of a coexisting sistemyc infection.\u003c/p\u003e \u003cp\u003eUltrasound is recommended as a screening tool for early detection of glandular involvement in neonates at high risk for parotiditis, particularly those with immune deficiencies or dehydration. Its ability to identify characteristic glandular changes, assess systemic involvement, guide further diagnostics and monitor treatment is crucial for providing prompt and effective care.\u003c/p\u003e \u003cp\u003eWhen neonatal parotitis occurs, especially with neurological signs or symptoms, CMV should be included in the differential diagnosis, given the virus' role in multiorgan involvement, including the parotid gland, and its association with immunodeficiency.\u003c/p\u003e \u003cp\u003eA comprehensive evaluation with imaging and laboratory studies is essential for timely identification and effective management of CMV infection. This strategy aims to prevent or, at least, mitigate long-term complications such as neurodevelopmental impairment. The coexistence of neonatal parotitis and congenital CMV infection presents diagnostic and therapeutic challenges, emphasizing the importance of thorough investigation in such cases.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThis case report has been writed according with the ethical standards of our institution. An informed verbal consent was obtained from the patient\u0026apos;s parents for the diagnostic procedures and treatment described in this report.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eOral informed consent was obtained from the patient\u0026apos;s parents for the publication of this case report and accompanying images. If a written consent is necessary for the Editor-inChief of this journal, please let us know and we\u0026rsquo;ll provide it as soon as possible.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAvailability of data and material\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe data used and analyzed during the current study are available from the corresponding author on reasonable request, subject to privacy and ethical restrictions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests related to this case report.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eFunding\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThis case report received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026apos; contributions\u0026nbsp;\u003c/h2\u003e\n\u003cul\u003e\n \u003cli\u003eEP: Conceptualization, data collection, wrote the initial draft and revised the manuscript.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMC: \u0026nbsp;Data analysis, literature review, and manuscript revision. Both authors read and approved the final manuscript.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eEM: Provided and described parotid ultrasound images. The author read and approved the final manuscript.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMC: Provided and described cranial ultrasound images. The author read and approved the final manuscript.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch2\u003eAcknowledgements\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe authors would like to thank the nursing and medical staff of the neonatal intensive care unit of Carlo Pizzardi Maggiore Hospital of Bologna. We also express our gratitude to the Elena Mengozzi MD of the radiology Department for her assistance with the ultrasound examinations and interpretations. Special thanks to Matilde Maria Ciccia MD for her review of the neurological findings, and for Mariasole Conte MD for her expert review of the manuscript.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eEl Omri M, Jemli S, Belakhdher M, Kermani W. Neonatal Suppurative Parotitis: Case Report and Review of Literature. Ear Nose Throat J. 2024 Mar 13:1455613241234281. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/01455613241234281\u003c/span\u003e\u003cspan address=\"10.1177/01455613241234281\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub ahead of print. PMID: 38476055.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMakhoul J, Lorrot M, Teissier N, Delacroix G, Doit C, Bingen E. al. Acute bacterial parotitis in infants under 3 months of age: a retrospective study in a pediatric tertiary care center. Arch Pediatr 2011; 181284\u0026ndash;128.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u0026Ouml;zdemir H, Karbuz A, Cift\u0026ccedil;i E, Fit\u0026ouml;z S, Ince E, Dogru U. Acute neonatal suppurative parotitis: a case report and review of the literature. Int J Infect Dis 2011; e15500\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAyala Curiel J. Gal\u0026aacute;n del R\u0026iacute;o P,Poza delVal C,Aguirre CondeA, Cotero Lavin A. Neonatal acute suppurative parotitis. Pediatr (Barc) 2004; 60274\u0026ndash;277.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAcute parotitis in. a newborn: a case report and review of the literature Liliana Costa, Laurentino M. Leal, Fernando Vales, Margarida Santos. Egypt J Otolaryngol. 2016;32:236\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDecembrino L, Ruffinazzi G, Russo F, Manzoni P, Stronati M. Monolateral suppurative parotitis in a neonate and review of literature. Int J Pediatr Otorhinolaryngol 2012; 76930\u0026ndash;933.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGreenberg MS, Glick M, Nghiem L, Stewart JCB, Hodinka R, Dubin G. Relationship of cytomegalovirus to salivary gland dysfunction in HIV-infected patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1997.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRole of high. resolution ultrasound in parotid lesions in children. Kushaljit Singh Sodhi *, Murray Bartlett, Nirmal Kumar Prabhu - Department of Medical Imaging, Royal Children\u0026rsquo;s Hospital, Flemington Road, Parkville, Melbourne, Victoria 3052, Australia.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eValutazione Antropometrica neonatale. Riferimento carte INeS. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.inescharts.com\u003c/span\u003e\u003cspan address=\"http://www.inescharts.com\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOrvidas LJ, Kasperbauer JL, Lewis JE, Olsen KD, Lesnick TG. Pediatric parotid masses. Arch Otolaryngol Head Neck Surg 2000; 126177\u0026ndash;184.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarcia CJ, Flores PA, Arce JD, Chuaqui B, Schwartz DS. Ultrasonography in the study of salivary gland lesions in children. Pediatr Radiol. 1998;28:418\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMakhoul J, Lorrot M, Teissier N, Delacroix G, Doit C, Bingen E. al. Acute bacterial parotitis in infants under 3 months of age: a retrospective study in a pediatric tertiary care center. Arch Pediatr 2011.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNeonatal Parotitis. A Case Report and Review of the LiteratureJulie Pollenus, MD,* and Stefaan Van Lierde, MD, PhD.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTapısız A, Belet N, C\u0026cedil;iftc\u0026cedil;i E, Fito\u0026uml;z S. I ˙nce E, Dog˘ru U\u0026uml;. Neonatal suppurative submandibular sialadenitis. Turk J Pediatr. 2009;51:180\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAcademy of Breastfeeding Medicine Clinical Protocol #36. The Mastitis Spectrum, Revised 2022 Katrina B. Mitchell,1 Helen M. Johnson,2 Juan Miguel Rodrı\u0026acute;guez,3 Anne Eglash,4 Charlotte Scherzinger,5 Irena Zakarija-Grkovic,6 Kyle Widmer Cash,7 Pamela Berens,8 Brooke Miller,9 and the Academy of Breastfeeding Medicine].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCristi\u0026micro;n J, Flores Jos\u0026Oslash; DA. Benedicto Chuaqui Dana S. Schwartz Ultrasonography in the study of salivary gland lesions in children, Pediatric Radiology.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDecembrino L, Ruffinazzi G, Russo F, Manzoni P, Stronati M. Monolateral suppurative parotitis in a neonate and review of literature. Int J Pediatr Otorhinolaryngol 2012; 76930\u0026ndash;933.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNeonatal suppurative parotitis possibly associated with congenital cytomegalovirus infection. and maternal methyldopa administration Yukiko Todoroki, 1 Hirokazu Tsukahara, 1 Masao Kawatani, 1 Yusei Ohshima, 1 Ken-Ichi Shukunami, 2 Fumikazu Kotsuji 2 And Mitsufumi Mayumi 1 Departments of 1 Pediatrics and 2 Obstetrics and Gynecology, Faculty of Medical Sciences, University of Fukui, Fukui, Japan.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVariend S, O\u0026rsquo;Neill D, Arnold P. The possible significance of cytomegaloviral parotitis in infant and early childhood deaths. Arch Pathol Lab Med. 1997;121:1272\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNeonatal I. John Tregoning, Imperial College London, UK, British Society for Immunology.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCranial ultrasound in congenital cytomegalovirus infection. Lidija Banjac*, Gorica Banjac Department of Neonatology, Clinical Center of Montenegro, Podgorica, Montenegro; Cranial Ultrasound Scanning and Prediction of Outcome in Newborns with Congenital Cytomegalovirus Infection Gina Ancora,Marcello Lanari. J Pediatr, 2007.\u003c/span\u003e\u003c/li\u003e \u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"italian-journal-of-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"itjp","sideBox":"Learn more about [Italian Journal of Pediatrics](http://ijponline.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ITJP/default.aspx","title":"Italian Journal of Pediatrics","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"case report, Neonatal parotitis, Concurrent bacterial and viral infections in newborns, Congenital cytomegalovirus (CMV) infection, ultrasound in newborns","lastPublishedDoi":"10.21203/rs.3.rs-5306904/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5306904/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eINTRODUCTION\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInfections involving salivary glands in newborns, especially when affecting the parotid gland, are uncommon but can arise from secretory stasis and bacterial superinfection, typically caused by Staphylococcus aureus or Streptococcus species. The main risk factors include dehydration, prematurity and immunodeficiency. Clinical manifestations commonly involve swelling, tenderness and purulent discharge. Management generally consists of intravenous antibiotics with surgical intervention reserved for complications. Ultrasound plays a critical role in diagnosis and management of the disease, especially when there is no purulent material from Stensen's duct available for analysis. Early recognition and appropriate treatment are crucial for preventing severe outcomes in these cases.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCASE REPORT\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe report a case of a 7-day-old full-term, breastfed girl admitted with right preauricular swelling and poor feeding. Born without complications, her symptoms also included irritability and purulent discharge from the right Stensen’s duct. Lab tests showed elevated white blood cells and neutrophilia, and ultrasound confirmed an enlarged right parotid gland with an abscess.\u003c/p\u003e\n\u003cp\u003eEmpirical antibiotics, clindamycin and cefotaxime, were initiated. Cultures identified Staphylococcus aureus in both the Stensen’s duct discharge and the mother’s milk. Antibiotics were adjusted to clindamycin and later cefaclor.\u003c/p\u003e\n\u003cp\u003eFurther investigations for congenital infections through brain ultrasound revealed cysts and vascular abnormalities, and CMV was diagnosed from urine and salivary samples, despite maternal immunity. The patient responded well to antibiotics, showing reduced swelling and normal feeding. She was discharged after 10 days, fully recovered, with follow-up for CMV ongoing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONCLUSION\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn neonates with acute parotitis, especially with neurological signs, CMV should be considered due to its multiorgan involvement and link to immunodeficiency. Adequate imaging and laboratory studies are crucial for early diagnosis, guiding treatment and preventing long-term complications.\u003c/p\u003e","manuscriptTitle":"A rare duo: bacterial parotitis and CMV in a neonate – Case report and diagnostic challenges","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-10 15:43:22","doi":"10.21203/rs.3.rs-5306904/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2024-11-09T05:51:27+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2024-11-05T15:35:54+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-11-05T11:18:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-30T07:43:59+00:00","index":"","fulltext":""},{"type":"submitted","content":"Italian Journal of Pediatrics","date":"2024-10-23T19:25:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"italian-journal-of-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"itjp","sideBox":"Learn more about [Italian Journal of Pediatrics](http://ijponline.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ITJP/default.aspx","title":"Italian Journal of Pediatrics","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ab4b98e7-5470-4151-8514-d9f677664574","owner":[],"postedDate":"December 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-05-09T11:18:31+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-10 15:43:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5306904","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5306904","identity":"rs-5306904","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}