Covid-19 associated parotitis in a 4-year-old boy

Clinical orofacial manifestations in COVID-19 patients have been reported in recent studies, including oral ulcers, oral vesiculobullous lesions and acute parotitis.1 Most reported cases of acute parotitis associated with COVID-19 involved adults, and only a few paediatric cases were reported. We present the case of a 4-year-old boy with left-side painful facial swelling, who presented with a 4-day history of left sided, painful, facial swelling with low grade fever on the first day and refused to eat. On the second day, he developed high fever and his cheek, particularly at the pre-auricular area, swelled even more. Except for the second dose of measles–mumps–rubella vaccine, the boy's immunisations were up to date. The local doctor diagnosed mumps, but the parents decided to seek a second opinion at our hospital. Before 10 days, before facial swelling, the boy had low grade fever, mild cough and was diagnosed with COVID-19 by positive SARS-CoV-2 RT-PCR; his fever lasted for a few days. On examination, the patient had normal vital signs and moderate left-sided cheek, pre-auricular swelling without erythema, but with pain on palpitation. The rest of his physical examination was unremarkable. Laboratory investigation revealed normal full blood count, serum C-reactive protein was 24.8 mg/L (normal < 10), serum amylase was 4.86 μkat/L (normal 0.4–1.7), normal AST, ALT. Mumps-IgM was negative. The patient was managed with analgesia. At follow-up, after 3 days, his facial swelling had resolved. Acute parotitis has been reported in association with COVID-19 in adults, usually unilateral with onset mostly 1–3 days from the beginning of COVID-19 symptoms. In a study in adults, computed tomography imaging demonstrated parotid and submandibular gland enlargement with heterogeneous enhancement and attenuation consistent with sialadenitis.2 There is a paucity of reports in children. Two cases developed right-side facial swelling on the third and fourth day of COVID-19,3, 4 there were no detail in another two cases (10 and 13 years old).5 The early onset of parotitis in the COVID-19 disease indicates that SARS-CoV-2 can cause salivary gland infection as happens with mumps and other Paramyxoviruses. Our patient developed parotitis after recovery from COVID-19, which is suggestive of an immune-mediated parotitis. To conclude, acute parotitis is a possible early manifestation of COVID-19, but parotitis can also occur as a late manifestation when the child has clinically recovered from the infection.