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Live viral vaccines are typically contraindicated in pregnancy; however, vaccination of children should not be delayed due to a pregnant family member.
Immunization of contacts protects against future (but not current) exposures.
DIAGNOSIS
HISTORY
- Parotid swelling peaks in 1 to 3 days and lasts 3 to 7 days.
- Clinical diagnosis (swelling of one or both parotid glands):
- Lasting ≥2 days
- No other apparent cause
- Rare presentation of meningitis without parotitis (1 " 10%)
- Up to ’
; of individuals with mumps are asymptomatic.
- Rare prodrome of fever, neck muscle ache, and malaise
- Sour foods cause pain in parotid gland region.
- Moderate fever, usually not >104 °F (40 °C):
- High fever frequently is associated with complications.
PHYSICAL EXAM
- Painful parotid swelling (unilateral or bilateral) obscures angle of mandible and elevates earlobe
- Meningeal signs in 15%, encephalitis in 0.5%
- Rarely arthritis, orchitis, thyroiditis, mastitis, pancreatitis, oophoritis, myocarditis
- Rare maculopapular, erythematous rash
- Up to 50% of cases may be very mild
- Redness at opening of Stensen duct but no pus
- Swelling in sternal area; rare, but pathognomonic of mumps
DIFFERENTIAL DIAGNOSIS
- If not epidemic, other viruses are more common: parainfluenza parotitis, Epstein-Barr virus, coxsackievirus, adenovirus, parvovirus B19
- Suppurative parotitis: often associated with Staphylococcus aureus (presence of Wharton duct pus on massaging parotid gland essentialy excludes diagnosis of mumps)
- Recurrent allergic parotitis
- Salivary calculus with intermittent swelling
- Lymphadenitis from any cause, including HIV infection
- Cytomegalovirus parotitis in immunocompromised patients
- Mikulicz syndrome: chronic, painless parotid and lacrimal gland swelling of unknown cause that occurs in tuberculosis, sarcoidosis, lupus, leukemia, lymphosarcoma, and salivary gland tumors
- Sj Άgren syndrome, diabetes mellitus, uremia, malnutrition
- Drug-related parotid enlargement (iodides, guanethidine, phenothiazine)
- Other causes of the complications of mumps (meningoencephalitis, orchitis, oophoritis, pancreatitis, polyarthritis, nephritis, myocarditis, prostatitis)
- Mumps orchitis must be differentiated from testicular torsion and from chlamydial or bacterial orchitis. (Testicular sonogram can be useful.)
DIAGNOSTIC TESTS & INTERPRETATION
- Three special tests used to confirm an outbreak " if positive, report to health department (1)[A]
- IgM titer (positive by day 5 in 100% of nonimmunized patients)
- Swab of parotid duct or other affected salivary ducts for viral culture
- Rise in IgG titer samples; test should be ordered if patient previously immunized: 1st sample within 5 days of onset, and 2nd, 2 weeks later.
- Other potential findings: elevated serum amylase; CSF leukocytosis, or leukopenia.
- Testicular ultrasound may help differentiate mumps orchitis from testicular torsion.
Diagnostic Procedures/Other
If meningitis is present, lumbar puncture to exclude bacterial process. CSF pleocytosis, usually lymphocytes, is found in 65% of patients with parotitis.
Test Interpretation
Periductal edema and lymphocytic infiltration in affected glands on biopsy
TREATMENT
- No specific antiviral therapy, only supportive care (1)[A],(4)[C]
- Analgesics to relieve pain
- Avoid corticosteroids for mumps orchitis because they can reduce testosterone concentrations and increase testicular atrophy.
- IVIG only successful for certain autoimmune-based sequelae:
- Postinfectious encephalitis
- Guillain-Barre syndrome
- ITP
- Interferon-α2b improved severe bilateral orchitis but did not decrease testicular atrophy in small studies (5)[B].
GENERAL MEASURES
- Rarely need to hospitalize patients with high fever, pancreatitis, or CNS symptoms for supportive care, steroids, or interferon using appropriate isolation precautions
- Orchitis
- Ice packs to scrotum can help to relieve pain.
- Scrotal support with adhesive bridge while recumbent and/or athletic supporter while ambulatory
MEDICATION
First Line
- Analgesics and anti-inflammatory medications (acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs]) may diminish pain and swelling in acute orchitis and arthritis mumps.
- May use acetaminophen for fever and/or pain
- Precautions: Avoid aspirin for pain in children as previously associated with Reye syndrome.
Second Line
- Interferon-α2b
- Chinese medicinal herbs and acupuncture have not shown benefit in randomized controlled trials (6,7).
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
- Hospitalize only if CNS symptoms occur.
- Outpatient supportive care if no complications
IV Fluids
If severe nausea or vomiting accompanies pancreatitis
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Mumps orchitis:
- Bed rest and local supportive clothing (e.g., two pairs of briefs) or adhesive-tape bridge
- Withhold from school until no longer contagious (9 days after onset of pain)
Patient Monitoring
Most cases will be mild. Monitor hydration status.
DIET
Liquid diet if unable to chew
PATIENT EDUCATION
Orchitis is common in older children but rarely results in sterility, even if bilateral.
PROGNOSIS
- Complete recovery is typical; immunity is lifelong
- Transient sensorineural hearing loss in 4% of adults
- Recurrence after 2 weeks may be nonepidemic parotitis
COMPLICATIONS
- May precede, accompany, or follow salivary gland involvement and may occur (rarely) without primary involvement of the parotid gland
- Orchitis is common (30%) in postpubertal boys:
- It starts within 8 days after parotitis
- Impaired fertility in 13%; absolute sterility is rare
- Meningitis (1 " 10%) or encephalitis (0.1%) may present 5 to 10 days after 1st symptoms of illness. Aseptic meningitis is typically mild, but meningoencephalitis may lead to seizures, paralysis, hydrocephalus, or (in 2% of cases), death.
- Acute cerebellar ataxia has been reported after mumps infections; self-resolving in 2 to 3 weeks.
- Oophoritis in 7% of postpubertal females; no decreased fertility
- Pancreatitis, usually mild
- Nephritis, thyroiditis, and arthralgias are rare.
- Myocarditis: usually mild, but may depress ST segment; may be linked to endocardial fibroelastosis
- Deafness: 1/15,000 unilateral nerve deafness; may not be permanent
- Inflammation about the eye (keratouveitis) is rare.
- Dacryoadenitis, optic neuritis
Pediatric Considerations
Orchitis is more common in adolescents.
Young children are less likely to develop complications.
Most complications occur in postpubertal group
Avoid aspirin use in children with viral symptoms.
Pregnancy Considerations
Disease may increase the rate of spontaneous pregnancy loss in 1st trimester. Perinatal mumps often has a benign course.
REFERENCES
11 Centers for Disease Control and Prevention. Overview of mumps. http://www.cdc.gov/mumps/about/index.html22 Gouma S, Sane J, Gijselaar D, et al. Two major mumps genotype G variants dominated recent mumps outbreaks in the Netherlands (2009 " 2012). J Gen Virol. 2014;95(Pt 5):1074 " 1082.33 Fiebelkorn AP, Lawler J, Curns AT, et al. Mumps postexposure prophylaxis with a third dose of measles-mumps-rubella vaccine, Orange County, New York, USA. Emerg Infect Dis. 2013;19(9):1411 " 1417.44 Davis NF, McGuire BB, Mahon JA, et al. The increasing incidence of mumps orchitis: a comprehensive review. BJU Int. 2010;105(8):1060 " 1065.55 Yapanoglu T, Kocaturk H, Aksoy Y, et al. Long-term efficacy and safety of interferon-alpha-2B in patients with mumps orchitis. Int Urol Nephrol. 2010;42(4):867 " 871.66 Shu M, Zhang YQ, Li Z, et al. Chinese medicinal herbs for mumps. Cochrane Database Syst Rev. 2012;(9):CD008578.77 He J, Zheng M, Zhang M, et al. Acupuncture for mumps in children. Cochrane Database Syst Rev. 2012;(9):CD008400.
ADDITIONAL READING
- Flaherty DK. The vaccine-autism connection: a public health crisis caused by unethical medical practices and fraudulent science. Ann Pharmacother. 2011;45(10):1302 " 1304.
- MacDonald N, Hatchette T, Elkout L, et al. Mumps is back: why is mumps eradication not working? Adv Exp Med Biol. 2011;697:197 " 220.
- Shirts BH, Welch RJ, Couturier MR. Seropositivity rates for measles, mumps, and rubella IgG and costs associated with testing and revaccination. Clin Vaccine Immunol. 2013;20(3):443 " 445.
- Zamir CS, Schroeder H, Shoob H, et al. Characteristics of a large mumps outbreak: clinical severity, complications and association with vaccination status of mumps outbreak cases. Hum Vaccin Immunother. 2015;11(6):1413 " 1417.
CODES
ICD10
- B26.9 Mumps without complication
- B26.1 Mumps meningitis
- B26.2 Mumps encephalitis
- B26.0 Mumps orchitis
- B26.83 Mumps nephritis
- B26.89 Other mumps complications
- B26.84 Mumps polyneuropathy
- B26.82 Mumps myocarditis
- B26.81 Mumps hepatitis
- B26.3 Mumps pancreatitis
- B26.85 Mumps arthritis
ICD9
- 072.9 Mumps without mention of complication
- 072.1 Mumps meningitis
- 072.2 Mumps encephalitis
- 072.0 Mumps orchitis
- 072.79 Other mumps with other specified complications
- 072.72 Mumps polyneuropathy
- 072.71 Mumps hepatitis
- 072.3 Mumps pancreatitis
- 072.8 Mumps with unspecified complication
SNOMED
- 36989005 Mumps (disorder)
- 44201003 Mumps meningitis (disorder)
- 31646008 Mumps encephalitis
- 78580004 mumps orchitis (disorder)
- 10665004 mumps pancreatitis (disorder)
- 240526004 Mumps parotitis
CLINICAL PEARLS
- Mumps is a clinical diagnosis based on swelling of ≥1 parotid glands for ≥2 days without other obvious cause. Confirmatory testing must be done in epidemic settings.
- Ultrasound is useful to distinguish testicular torsion from testicular pain related to mumps orchitis.
- A history of vaccination with MMR does not exclude mumps. The MMR vaccine is 68 " 95% effective after a series of two immunizations. Immunity commonly wanes over time.