Probably viral....right?

Morning report today presented the case of an otherwise well patient presenting with fever, dyspnea, cough, preceded by unilateral parotitis. 

The patient had a travel history to the middle east prior to presentation during which the symptoms developed. 


One diagnosis? Two? Occam's razor? Hickam's dictam?

DDx of parotitis:
Think about unilateral vs bilateral...although the rules often break down.

Unilateral is often due to a structural problem such as stones, or malignancy.
Stones can be massaged out and interestingly can be aided in expulsion by acidic environments ie lime or lemon juice. 

Bilateral causes (although can present unilateral)
- Infectious: mumps, viral (EBV, CMV, HIV flu, paraflu, rsv, hmpv), TB, lyme 
- Autoimmune: SLE, Sjogren's, sicca
- Inflammatory: secondary to bulimia nervosa

DDx of fever, dyspnea, cough 

Usual suspects
- Bacterial pneumonia
- Viral illnesses (see above)

but also consider if travel history consistent....

Novel influenza illnesses

MERS-CoV - Middle East Respiratory Syndrome - coronavirus
- first described in 2012
- 139 cases to date - France, Italy, Jordan, Qatar, Saudi Arabia, UK, UAE
- morality is reported anywhere from 30-50%
- details here from the CDC website

Public Health principles: isolate, personal protection, alert PHL

Back to the case....
On presentation appeared relatively well, but did require oxygen. NP swab was negative (including negative for MERS-CoV)...however bronchoscopy was positive for RSV.

In a retrospective cohort study by Bogoch et. al in 2013, they found that 6.9% of cases will have a negative NP swab, but will be positive on bronchoscopy.
See here for the article

A word on RSV:

Not just a pediatric virus, can infect adults.
While most people will recover outside of hospital, those that require admission can be very sick and people can die from RSV. Only to highlight to take this seriously.
NP swabs may be negative as the virus may have had contiguous spread to the lower tract.

Falsey et. al in 2005 published in the NEJM results of a prospective cohort study evaluating respiratory illnesses in the elderly and found that RSV accounted for similar rates of infection, hospitalization, ICU requirements, mortality as compared to influenza A.

Click NEJM RSV 2005 article  to view. 

Lastly...what about the parotid gland swelling?
On further history the patient endorsed dry eyes, dry mouth, serology came back as ANA positive and anti-La positive, and so was diagnosed as having Sjogren's syndrome.

Looks like Hickam was right in this case.