Mumps

Mumps

There are many conditions that I have learned about, yet never seen. Some conditions I was not wise enough to diagnose.  Others conditions patient rarely develop have because of vaccinations!  Unfortunately, despite vaccinations, there are still outbreaks of these important conditions.  We’ve discussed Measles and Pertussis previously. Now, let us look at Mumps!

 

Mumps: Basics

  • Mumps virus is a Paramyxoviridae virus.
  • Mumps is a vaccine preventable disease, although does still occur in outbreaks.
    • Large outbreaks recorded in UK (2004), USA (2006, 2009) and Netherlands (2009) [Dayan, 2008; Barskey, 2012; Sane, 2014]
      • Close to home (like recently in Charlotte).
    • Outbreaks have occurred primarily in college-aged adults and patients too old or too young to have been vaccinated.
    • The vaccine is not 100% effective and there are populations that are unvaccinated.
    • So, while the vaccine has helped substantially, you still may encounter a patient with mumps!
  • Compared to measles and pertussis, mumps is generally more benign. [Hviid, 2008]
    • In pre-vaccine era, mumps was a major cause of aseptic meningitis. [Rotbart, 2000]
  • Mumps shows a seasonality that shows peak in Winter and Spring.
  • Mumps is a self-limited illness and resolves within a few weeks.

 

Mumps: Presentation

  • Like many childhood viral illnesses… it often looks benign at first.
    • Prodrome
      • Fever, malaise, headache.
      • Some will have ear and/or jaw pain.
      • Unfortunately, can be contagious during this time. [Kutty, 2010]
  • Other clinical findings:
    • Parotitis
      • Most prevalent finding!
      • Seen in 95% of symptomatic patients! [Hviid, 2008]
      • Occurs in first 2 days of illness.
      • Usually resolves within 1-2 weeks.
      • Angle of mandible is obscured.
      • Bilateral involvement is common.
      • Can involve other salivary glands (not just parotid).
    • Aseptic Meningitis
      • Most common extra-salivary gland clinical finding.
      • CSF Pleocytosis is common (50%), but clinical meningitis occurs in only up to 15% of cases. [Hviid, 2008]
      • Encephalitis is rare (0.1%).
      • Permanent sequelae is rare.
    • Gonadal Involvement
      • Oophoritis (~5%) or orchitis (~30%) can occur.
      • Occurs 4-14 days after parotitis, but cases known to occur as late as 6 weeks after.
      • Testicle swelling and tenderness is usually unilateral. Bilateral in 15-30% of cases with orchitis. [Hviid, 2008]
      • Oophoritis can mimic appendicitis.
    • Pancreatitis

 

Mumps: Parotitis DDx

  • Obviously, other conditions can cause parotid swelling… and are likely more common! [Hviid, 2008]
  • When there is no Outbreak, consider these entities as being more probable.
  • Other Viral Infections
    • EBV
    • Parainfluenza virus
    • Adenovirus
    • Influenza A
    • Coxsakievirus
    • Parvo B19
    • Human herpesvirus 6
    • Acute HIV infection
  • Bacterial Infections
    • Staph
    • Atypical mycobacteria
  • Drugs
    • Phenothiazines
    • Iodines
    • Thiouracil
  • Miscellaneous
    • Salivary stones
    • Salivary tumors
    • Malnutrition
    • Diabetes
    • Sjigren’s Syndrome

 

Mumps: Diagnosis

  • Clinical definition = Acute onset of unilateral/bilateral parotid swelling or other salivary glands lasting 2 or more days without other clear cause.
  • Laboratory diagnosis is based on identifying the mumps virus.
    • Virus can be isolated from saliva, CSF, urine, or seminal fluid within the 1st week of symptoms!
    • RT-PCR is usually preferred over viral culture.
  • Serology (ex, IgM level) is not as helpful as RT-PCR and effected by timing of sample during illness and previous vaccination status.

 

Mumps: Treatment

  • Symptomatic primarily
  • Avoid salivary-stimulating foods (ex, acidic).
  • Keep away from pregnant women in 1st trimester.
  • Isolate with Standard and Droplet Precautions for 5 days after onset of parotitis. [Kutty, 2010]

 

References

Sukumaran L1, McNeil MM2, Moro PL2, Lewis PW2, Winiecki SK3, Shimabukuro TT2. Adverse Events Following Measles, Mumps, and Rubella Vaccine in Adults Reported to the Vaccine Adverse Event Reporting System (VAERS), 2003-2013. Clin Infect Dis. 2015 May 15;60(10):e58-65. PMID: 25637587. [PubMed] [Read by QxMD]

Kutty PK1, McLean HQ, Lawler J, Schulte C, Hudson JM, Blog D, Wallace G. Risk factors for transmission of mumps in a highly vaccinated population in Orange County, NY, 2009-2010. Pediatr Infect Dis J. 2014 Feb;33(2):121-5. PMID: 23995590. [PubMed] [Read by QxMD]

Sane J, Gouma S, Koopmans M, de Melker H, Swaan C, van Binnendijk R, Hahné S. Epidemic of mumps among vaccinated persons, The Netherlands, 2009-2012. Emerg Infect Dis. 2014 Apr;20(4):643-8. PMID: 24655811. [PubMed] [Read by QxMD]

Abrams S, Beutels P, Hens N. Assessing mumps outbreak risk in highly vaccinated populations using spatial seroprevalence data. Am J Epidemiol. 2014 Apr 15;179(8):1006-17. PMID: 24573540. [PubMed] [Read by QxMD]

Barskey AE1, Schulte C, Rosen JB, Handschur EF, Rausch-Phung E, Doll MK, Cummings KP, Alleyne EO, High P, Lawler J, Apostolou A, Blog D, Zimmerman CM, Montana B, Harpaz R, Hickman CJ, Rota PA, Rota JS, Bellini WJ, Gallagher KM. Mumps outbreak in Orthodox Jewish communities in the United States. N Engl J Med. 2012 Nov;367(18):1704-13. PMID: 23113481. [PubMed] [Read by QxMD]

Davis NF1, McGuire BB, Mahon JA, Smyth AE, O’Malley KJ, Fitzpatrick JM. The increasing incidence of mumps orchitis: a comprehensive review. BJU Int. 2010 Apr;105(8):1060-5. PMID: 20070300. [PubMed] [Read by QxMD]

Kutty PK1, Kyaw MH, Dayan GH, Brady MT, Bocchini JA, Reef SE, Bellini WJ, Seward JF. Guidance for isolation precautions for mumps in the United States: a review of the scientific basis for policy change. Clin Infect Dis. 2010 Jun 15;50(12):1619-28. PMID: 20455692. [PubMed] [Read by QxMD]

Hviid A1, Rubin S, Mühlemann K. Mumps. Lancet. 2008 Mar 15;371(9616):932-44. PMID: 18342688. [PubMed] [Read by QxMD]

Dayan GH1, Quinlisk MP, Parker AA, Barskey AE, Harris ML, Schwartz JM, Hunt K, Finley CG, Leschinsky DP, O’Keefe AL, Clayton J, Kightlinger LK, Dietle EG, Berg J, Kenyon CL, Goldstein ST, Stokley SK, Redd SB, Rota PA, Rota J, Bi D, Roush SW, Bridges CB, Santibanez TA, Parashar U, Bellini WJ, Seward JF. Recent resurgence of mumps in the United States. N Engl J Med. 2008 Apr 10;358(15):1580-9. PMID: 18403766. [PubMed] [Read by QxMD]

Rotbart HA1. Viral meningitis. Semin Neurol. 2000;20(3):277-92. PMID: 11051293. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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