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Case report: Grey scale and colour Doppler ultrasound appearance of acute sarcoidosis of the parotid gland
ClinicalRadiology (1994) 49, 425 426
Case Report: Grey Scale and Colour Doppler Ultrasound Appearance of Acute Sarcoidosis of the Parotid Gland I. M . G . K E L L Y , W . R. L E E S a n d R . W . E. W A T T S *
Department of Diagnostic Imaging, Middlesex Hospital, London and * The Consulting Rooms, Wellington Hospital, London Sarcoidosis is a relatively c o m m o n disease with protean clinical manifestations. Involvement of the parotid glands in the acute presentation is well recognized but the grey scale and colour Doppler appearances are less well so. These are described in a case where imaging and biopsy proved valuable in the diagnosis of acute sarcoid presenting as sicca syndrome. Kelly, I.M.G., L e e s , W . R . & W a t t s , R . W . E . (1994). Clinical Radiology 49, 4 2 5 - 4 2 6 . C a s e R e p o r t : G r e y Scale a n d C o l o u r D o p p l e r U l t r a s o u n d A p p e a r a n c e o f A c u t e Sarcoidosis o f the P a r o t i d Gland
CASE REPORT A 31 -year-old single male student presented with a 1 month history of painless swelling involving both sides of the face and of a swelling under the left upper eyelid. He denied any further symptoms except for some recent increase in weight and a sore throat at about the time when the swelling was first noted. The past medical history comprised mumps and morbilli in childhood. There was no history of sexual transmitted disease. Examination revealed bilateral firm enlargement of the parotid and left lacrimal glands, the latter was a little tender. There was no lymphadenopathy or submandibular gland enlargement. Examination was otherwise unremarkable. After the initial consultation the patient was seen a week later and by this time the right lacrimal gland had also enlarged and become slightly tender. His mouth now felt dry, he lacked energy and was intermittently febrile with temperatures ranging up to 37.1~ He subsequently developed some itching and soreness of the eyes. Blood tests including FBC, ESR and biochemistry were normal except for a slight derangement in liver transanainase levels. Viral serology was all within normal titres. DNA antibodies were negative. Angiotensin converting enzyme activity was 841U/1 (reference range 8 52). Grey scale ultrasound of the parotids was performed which showed
diffusely enlarged glands with the normal parenchymal pattern interspersed with small uniformly sized nodules of low echogenicity (Fig. 2). Colour Doppler imaging showed intense hypervascularity related to the whole parenchyma of the gland (Fig. 3). An ultrasound-guided trucut biopsy from the most superficial part of the gland avoiding branches of the facial nerve and arteries was performed which on histology showed non-caseating granulomas fully consistent with a diagnosis of sarcoidosis. Staining for TB and fungi was negative. A CXR showed bilateral hilar lymphadenopathy and a widespread nodular pattern throughout both lung fields with a midzone prominence entirely in keeping with the diagnosis. Pulmonary function tests showed a mixed obstructive/ restrictive impaired pattern. After 4 weeks on Prednisolone (40 mg/day) the swelling of the parotids and lacrimals had largely subsided but some facial rounding had developed. The dryness of the mouth and the soreness of the eyes also responded promptly. The patient felt much better although he still tired easily on walking or other exertion.
DISCUSSION T h e l i t e r a t u r e p e r t a i n i n g t o g r e y scale u l t r a s o u n d i m a g i n g o f t h e p a r o t i d g l a n d in s a r c o i d o s i s is s p a r s e ,
Fig. 1 - Grey scale ultrasound image of the parotid gland using a 7.5 MHz probe for the Acuson 128. A long white arrow marks the bright acoustic rim of the mandibular cortex. The relatively low to mixed echogenicity delineates the adjacent masseter muscle (short fat arrow). The normal parotid gland has a homogeneous high echogenic parenchyrnal appearance (large white arrow): Correspondence to: Dr I, M. G. Kelly, Department of Diagnostic Imaging, Middlesex Hospital, Mortimer Street, London WIN 8AA.
Fig. 2 The normal parenchymal pattern is replaced by a coarse heterogeneous appearance composed mainly of multiple small nodules of low echogenicity which have slight through transmission.
426
CLINICAL RADIOLOGY
Fig. 3 Grey scale appearance of the same gland with superimposed colour Doppler imaging. An intense multifocal increase in colour stain is seen.
amounting to eight cases from two papers, with no detail or illustration as to sonographic features [1,2]. One sentence and one table reference from these papers constitute the grey scale ultrasound literature of sarcoidosis of the parotid gland. Ultrasound was felt to contribute little useful information in the imaging diagnosis of this multisystem inflammatory disease. This case illustrates both the grey scale and colour Doppler appearances of acute parotid sarcoidosis and how valuable the choice of ultrasound was as a primary imaging investigative modality. The grey scale appearance suggested an active inflammatory process. This suggestion was consolidated by the hypervascularity seen on colour Doppler imaging and guided biopsy lead directly to a histological diagnosis. Colour Doppler guidance and biopsy from the most superficial part of the gland avoids damage to those branches of the external carotid and facial nerve that traverse the gland. The sonographic grey scale pattern is florid but probably nonspecific with a modest differential diagnosis including lymphocytic infiltration of Sjogren's, acute sialadenitis
and granulomatous conditions including sarcoidosis and tuberculosis, lymphoma, autoimmune sialectasia and lymphoepithelial cysts of HIV disease [3]. There is a greater body of literature relating to this sonographic differential diagnosis but both the grey scale and colour Doppler appearances of acute parotid sarcoidosis have not previously been described. These appearances are typical of granulomatous disease and more particularly of sarcoidosis as seen elsewhere with diffusely distributed foci of low echogenicity [4]. Although non-specific, it remains of great interest because the parotid is an easily accessible site for confirmatory aspiration cytology or biopsy. Although only 5% of patients with sarcoidosis have clinically manifest parotid involvement, some studies suggest subclinical involvement is much higher as positive histology has been found in 58% of patients undergoing systematic open biopsy [5,6]. The colour Doppler appearances are also of interest because there is little documented experience of colour Doppler in sarcoidosis of any system whatsoever. We know from our experience of other inflammatory pathologies such as acute and chronic prostatitis, including granulomatous prostatitis, that an intense increase in colour flow signal would not be unexpected in acute sarcoidosis [7]. Increased use of high resolution ultrasound and awareness as to the appearance of parotid sarcoidosis should increase the detection of pai'otid sarcoidosis which may prove convenient and valuable in the histological confirmation of the disease. REFERENCES 1 Gritzmann N. Sonography of the salivary glands. American Journal of Roentgenology 1989;153:161-166. 2 Iko BO, Chinwuba CE, Myers EM et al. Sarcoidosis of the parotid gland. British Journal of Radiology 1986;59:547 552. 3 Bradus R J, Hybarger P, Gooding GAW. Parotid gland: US findings in Sjogren syndrome. Radiology 1988;169:749 75I. 4 BurkeBJ, ParkerSH, HooperKDetal. Theultrasonicappearanceof coexistent epididymal and testicular sarcoidosis. Journal of Clinical Ultrasound 1990;18:522 526. 5 Siltzbach LE, James DG, Neville E et al. Course and prognosis of sarcoidosis around the world. American Journal of Medicine 1974; 57:847-852. 6 Brantley SD, Orzel JA, Weiland FL et al. Parotid gland biopsy and 67Ga imaging correlation in systemic sarcoidosis. Chest 1987;91(3): 403 -407. 7 Kelly IMG, Lees WR, Rickards D. Colour Doppler imaging and prostate disease. British Journal of Radiology 1992;65:(CS)144.
Case Report: Grey Scale and Colour Doppler Ultrasound Appearance of Acute Sarcoidosis of the Parotid Gland I. M . G . K E L L Y , W . R. L E E S a n d R . W . E. W A T T S *
Department of Diagnostic Imaging, Middlesex Hospital, London and * The Consulting Rooms, Wellington Hospital, London Sarcoidosis is a relatively c o m m o n disease with protean clinical manifestations. Involvement of the parotid glands in the acute presentation is well recognized but the grey scale and colour Doppler appearances are less well so. These are described in a case where imaging and biopsy proved valuable in the diagnosis of acute sarcoid presenting as sicca syndrome. Kelly, I.M.G., L e e s , W . R . & W a t t s , R . W . E . (1994). Clinical Radiology 49, 4 2 5 - 4 2 6 . C a s e R e p o r t : G r e y Scale a n d C o l o u r D o p p l e r U l t r a s o u n d A p p e a r a n c e o f A c u t e Sarcoidosis o f the P a r o t i d Gland
CASE REPORT A 31 -year-old single male student presented with a 1 month history of painless swelling involving both sides of the face and of a swelling under the left upper eyelid. He denied any further symptoms except for some recent increase in weight and a sore throat at about the time when the swelling was first noted. The past medical history comprised mumps and morbilli in childhood. There was no history of sexual transmitted disease. Examination revealed bilateral firm enlargement of the parotid and left lacrimal glands, the latter was a little tender. There was no lymphadenopathy or submandibular gland enlargement. Examination was otherwise unremarkable. After the initial consultation the patient was seen a week later and by this time the right lacrimal gland had also enlarged and become slightly tender. His mouth now felt dry, he lacked energy and was intermittently febrile with temperatures ranging up to 37.1~ He subsequently developed some itching and soreness of the eyes. Blood tests including FBC, ESR and biochemistry were normal except for a slight derangement in liver transanainase levels. Viral serology was all within normal titres. DNA antibodies were negative. Angiotensin converting enzyme activity was 841U/1 (reference range 8 52). Grey scale ultrasound of the parotids was performed which showed
diffusely enlarged glands with the normal parenchymal pattern interspersed with small uniformly sized nodules of low echogenicity (Fig. 2). Colour Doppler imaging showed intense hypervascularity related to the whole parenchyma of the gland (Fig. 3). An ultrasound-guided trucut biopsy from the most superficial part of the gland avoiding branches of the facial nerve and arteries was performed which on histology showed non-caseating granulomas fully consistent with a diagnosis of sarcoidosis. Staining for TB and fungi was negative. A CXR showed bilateral hilar lymphadenopathy and a widespread nodular pattern throughout both lung fields with a midzone prominence entirely in keeping with the diagnosis. Pulmonary function tests showed a mixed obstructive/ restrictive impaired pattern. After 4 weeks on Prednisolone (40 mg/day) the swelling of the parotids and lacrimals had largely subsided but some facial rounding had developed. The dryness of the mouth and the soreness of the eyes also responded promptly. The patient felt much better although he still tired easily on walking or other exertion.
DISCUSSION T h e l i t e r a t u r e p e r t a i n i n g t o g r e y scale u l t r a s o u n d i m a g i n g o f t h e p a r o t i d g l a n d in s a r c o i d o s i s is s p a r s e ,
Fig. 1 - Grey scale ultrasound image of the parotid gland using a 7.5 MHz probe for the Acuson 128. A long white arrow marks the bright acoustic rim of the mandibular cortex. The relatively low to mixed echogenicity delineates the adjacent masseter muscle (short fat arrow). The normal parotid gland has a homogeneous high echogenic parenchyrnal appearance (large white arrow): Correspondence to: Dr I, M. G. Kelly, Department of Diagnostic Imaging, Middlesex Hospital, Mortimer Street, London WIN 8AA.
Fig. 2 The normal parenchymal pattern is replaced by a coarse heterogeneous appearance composed mainly of multiple small nodules of low echogenicity which have slight through transmission.
426
CLINICAL RADIOLOGY
Fig. 3 Grey scale appearance of the same gland with superimposed colour Doppler imaging. An intense multifocal increase in colour stain is seen.
amounting to eight cases from two papers, with no detail or illustration as to sonographic features [1,2]. One sentence and one table reference from these papers constitute the grey scale ultrasound literature of sarcoidosis of the parotid gland. Ultrasound was felt to contribute little useful information in the imaging diagnosis of this multisystem inflammatory disease. This case illustrates both the grey scale and colour Doppler appearances of acute parotid sarcoidosis and how valuable the choice of ultrasound was as a primary imaging investigative modality. The grey scale appearance suggested an active inflammatory process. This suggestion was consolidated by the hypervascularity seen on colour Doppler imaging and guided biopsy lead directly to a histological diagnosis. Colour Doppler guidance and biopsy from the most superficial part of the gland avoids damage to those branches of the external carotid and facial nerve that traverse the gland. The sonographic grey scale pattern is florid but probably nonspecific with a modest differential diagnosis including lymphocytic infiltration of Sjogren's, acute sialadenitis
and granulomatous conditions including sarcoidosis and tuberculosis, lymphoma, autoimmune sialectasia and lymphoepithelial cysts of HIV disease [3]. There is a greater body of literature relating to this sonographic differential diagnosis but both the grey scale and colour Doppler appearances of acute parotid sarcoidosis have not previously been described. These appearances are typical of granulomatous disease and more particularly of sarcoidosis as seen elsewhere with diffusely distributed foci of low echogenicity [4]. Although non-specific, it remains of great interest because the parotid is an easily accessible site for confirmatory aspiration cytology or biopsy. Although only 5% of patients with sarcoidosis have clinically manifest parotid involvement, some studies suggest subclinical involvement is much higher as positive histology has been found in 58% of patients undergoing systematic open biopsy [5,6]. The colour Doppler appearances are also of interest because there is little documented experience of colour Doppler in sarcoidosis of any system whatsoever. We know from our experience of other inflammatory pathologies such as acute and chronic prostatitis, including granulomatous prostatitis, that an intense increase in colour flow signal would not be unexpected in acute sarcoidosis [7]. Increased use of high resolution ultrasound and awareness as to the appearance of parotid sarcoidosis should increase the detection of pai'otid sarcoidosis which may prove convenient and valuable in the histological confirmation of the disease. REFERENCES 1 Gritzmann N. Sonography of the salivary glands. American Journal of Roentgenology 1989;153:161-166. 2 Iko BO, Chinwuba CE, Myers EM et al. Sarcoidosis of the parotid gland. British Journal of Radiology 1986;59:547 552. 3 Bradus R J, Hybarger P, Gooding GAW. Parotid gland: US findings in Sjogren syndrome. Radiology 1988;169:749 75I. 4 BurkeBJ, ParkerSH, HooperKDetal. Theultrasonicappearanceof coexistent epididymal and testicular sarcoidosis. Journal of Clinical Ultrasound 1990;18:522 526. 5 Siltzbach LE, James DG, Neville E et al. Course and prognosis of sarcoidosis around the world. American Journal of Medicine 1974; 57:847-852. 6 Brantley SD, Orzel JA, Weiland FL et al. Parotid gland biopsy and 67Ga imaging correlation in systemic sarcoidosis. Chest 1987;91(3): 403 -407. 7 Kelly IMG, Lees WR, Rickards D. Colour Doppler imaging and prostate disease. British Journal of Radiology 1992;65:(CS)144.