To present a case of acute bacterial parotitis (ABP) due to angioedema from IV alteplase and prolonged macroglossia in the setting of a right middle cerebral artery (MCA) stroke. 

CASE REPORT:  A 73 year-old woman with hypertension, hypothyroidism and remote ovarian cancer presented with an acute right MCA syndrome (NIHSS 18) and was found to have a carotid terminus ‘T’ occlusion.  She was treated with IV alteplase and mechanical thrombectomy with TICI IIB flow. During intubation for endovascular therapy, macroglossia and dried blood in her oropharynx were discovered, possibly as a result of alteplase-associated angioedema. There was no history of trauma prior to presentation, and she was extubated successfully after the procedure.  During subsequent days the macroglossia persisted, and she maintained an open-mouth breathing posture.  She developed severe dry mouth with odynophagia, limited lingual range of motion, and significant mucous crusting.  On hospital day 6, she was noted to have swelling, erythema and exquisite tenderness of the right cheek.  Otolaryngology was consulted and diagnosed her with acute bacterial parotitis (ABP).  Culture revealed Staphylococcus aureus as as well as Candida sp.  She was treated with a combination of 14 days of Unasyn and Augmentin.  General measures included IV fluids, cool moist air shovel mask, hot packs, parotid massage and sialogogues. Oral hygiene was provided using frequent washing with chlorhexidine.  She gradually improved, and the parotitis resolved over several weeks. 

ABP significantly increased morbidity and length of stay in this patient.  It has been previously described in acute stroke but not in association with alteplase-induced angioedema. This rare complication was caused by a combination of angioedema, orolingual weakness leading to open mouth posture, dry mucosal membranes and decreased salivatory output.  This highlights the importance of prompt recognition of angioedema, adequate IV hydration, and thorough mouth care in stroke patients.