Presentation
Unilateral pain and swelling of the left cheek especially on eating and chewing.
Patient Data
There is significant motion and other MRI artefact degrading image acquisition in a restless and claustrophobic patient. The study was prematurely curtailed.
The limited images confirmed parotomegaly with a heterogeneous signal intensity. The left Stensen's duct is mildly dilated.
There is nasopharyngeal lymphoproliferative hyperplasia, bilateral mastoid effusions, and cervical lymph adenopathy.
Axial asymmetry in a restless and claustrophobic patient.
There is parotomegaly with a heterogeneous density. Specifically, there is a fatty replacement, with punctate, small and medium calcifications/ sialoliths. There is a small sialolith within the distal left Stensen's duct with mild proximal duct distension, especially in comparison to the asymptomatic right parotid gland and duct. The submandibular glands are also heterogeneous in appearance, however, there are no calcifications/sialoliths.
There is a right sided mastoid effusion and opacified right middle ear cavity.The MRI identified left mastoid effusion is poorly appreciated.
Case Discussion
This is an example of the salt and pepper sign of the parotid glands in a suspected HIV-positive patient and benign lymphoepithelial lesions. Typically on MRI, the fatty replacement is the "salt" - bright on both T1 and T2 imaging, while the "pepper" is the punctate calcifications and calculi and hence dark on both T1 and T2 imaging. Remember the appearance is "reversed" on CT imaging, the fat appears low density and the calcifications/ calculi are of high density.
In this instance, there is a distal left Stensen's (parotid) duct calculus causing obstruction and accounting for the acute symptomatology and presentation.
The additional findings suggest likely background immune suppression for further investigation and confirmation.
The salivary gland appearance above may also be found in Sjogren's syndrome.
The patient was referred for MRI sialography, however, due to a restless and claustrophobic patient this was not possible in a nonsedated state and we reverted to a non-contrast CT study, which was beneficial and provided the diagnosis.
The urea and electrolytes were not available at the time of presentation and hence iodinated contrast was not injected.
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