Mumps/Parotitis, Pediatric

Basics

Description

Centers for Disease Control and Prevention (CDC) clinical case definition for mumps: illness with acute onset of unilateral or bilateral, tender, self-limited swelling of the parotid or other salivary gland, lasting ≥2 days, without other apparent cause

Epidemiology

Incidence

In the prevaccine era, 90% of all children contracted mumps virus infection by 14 years of age.
Incidence of this once very common disease has declined dramatically since the advent of universal childhood immunization.
Outbreaks, however, continue to occur.
200 " 300 cases per year reported in the United States since 2001
In early 2006, a large epidemic broke out in Iowa and neighboring states:
- 11 states reported >2,500 cases.
- Largest epidemic since 1988
- Median age of patient was 21 years (mostly college students)
- Led CDC and American College Health Association to recommend 2 doses of MMR vaccine to be a requirement for college entry
In 2006, 81 " 100% of children entering United States schools had received 2 doses of mumps vaccine.
In 2009 " 2010, an outbreak of mumps occurred in a highly vaccinated population in the northeastern United States. Intense exposure facilitated transmission. Previous vaccination appeared to limit the severity of disease.
Seroprevalence of antibody to mumps virus in the United States population (1999 " 2004) is estimated at 90%.

General Prevention

2 combination mumps vaccine are used:
- MMR: Measles, mumps, rubella
- MMRV: Measles, mumps, rubella, varicella
A single 0.5-mL SC injection of live mumps vaccine (MMR or MMRV) is recommended at 12 " 15 months.
A second vaccination is recommended between 4 and 6 years of age.
The efficacy of 2 doses of vaccines is estimated at approximately 80 " 90%.
Primary vaccine failure and waning vaccine-induced immunity have been reported.
Some have suggested the need for a 3rd vaccination to mitigate waning immunity. Preliminary studies indicate no increase in adverse effects after a 3rd vaccination.
The 1st dose of MMR vaccine sometimes causes fever and rash:
- These symptoms occur 7 " 12 days after immunization.
- Measles component is usually the culprit.
Both MMRV and MMR vaccines, but not varicella vaccine alone, are associated with increased outpatient fever visits and seizures 5 " 12 days after vaccination in 12- to 23-month-olds, with MMRV vaccine increasing fever and seizure twice as much as the MMR + varicella vaccine.
Vaccine should not be administered to children who are immunocompromised by disease or pharmacotherapy, as well as to pregnant women.
If a child has recently received immune globulin, administration of MMR vaccine should be delayed (for 3 " 11 months depending on the dose of IG).
Children with HIV infection who are not severely immunocompromised should be immunized with the MMR vaccine.
1 attack of mumps (clinical or subclinical) usually confers lifelong immunity.
Links of the MMR vaccine to autism by Andrew Wakefield MB, BS in a 1998 Lancet publication have now been exposed as fraudulent.

Pathophysiology

The virus is spread by contact with respiratory secretions.
The mumps virus enters via the respiratory tract, and a viremia ultimately ensues.
The virus spreads to many organs, including the salivary glands, gonads, pancreas, and meninges.
Period of communicability: 7 days before to 9 days after onset of parotid swelling
Most communicable period: 2 " 3 days before to 5 days after onset of parotid swelling
Incubation period: 12 " 25 days after exposure
Humans are the only known host for mumps.

Etiology

Epidemic parotitis is caused by mumps, an RNA virus in the Paramyxoviridae family.
Other viral causes of parotitis include Epstein-Barr virus, cytomegaloviruses, influenza, parainfluenza, and enteroviruses
Parotid enlargement can be an initial sign in HIV-infected children.
Bacterial cases are usually secondary to Staphylococcus aureus (suppurative parotitis).
Streptococci, gram-negative bacilli, and anaerobic infections are also possible.
Rare childhood cases may be secondary to an obstructing calculus, foreign body (sesame seed), tumors, sarcoid, Sj Άgren syndrome, or various drugs (antihistamines, phenothiazines, iodine-containing drugs/contrast media).

Commonly Associated Conditions

Salivary adenitis
- Most common manifestation of mumps
- 1/3 of cases occur subclinically
Epididymoorchitis
- Up to 35% of adolescent mumps cases are complicated by orchitis.
- Orchitis develops within 4 " 10 days of the onset of the parotid swelling.
- Sterility is uncommon.
Aseptic meningitis
Pancreatitis
- Mild inflammation is common.
- Serious involvement is rare.

Diagnosis

History

Prodromal symptoms uncommon but may include the following:
- Fever
- Anorexia
- Myalgia
- Headache
Onset usually pain and swelling in front of and below ear
Swelling
- Usually starts on one side of the face, then progresses to the other
Mild fever
- Usually accompanies parotid swelling
Dysphagia and dysphonia are common.
Testicular pain and swelling, along with constitutional symptoms, occurs in postpubertal males usually 1 week after parotid swelling but occasionally simultaneously or alone.
Epigastric pain and constitutional symptoms with pancreatic involvement
Fever, headache, and stiff neck with meningitis
Behavioral changes, seizures, and other neurologic abnormalities are rare.
Other symptoms are analogous to the particular organ involved.

Physical Exam

Nonerythematous, tender parotid swelling (erythema seen with suppurative parotitis)
Swelling ultimately obscures the mandibular ramus.
The ear is displaced upward and outward.
Importantly, up to 30% of symptomatic cases of mumps are not associated with parotitis.
Submaxillary and sublingual glands also may be swollen.
Inflammation may be noted intraorally at the orifice of Stensen duct.
Presternal edema is occasionally noted.
Mumps are infrequently associated with truncal rash.
Tender, edematous testicle in mumps orchitis (usually unilateral)
Ask the patient if the pain (at the parotid) intensifies with the tasting of sour liquids:
- Have the patient suck on a lemon drop or lemon juice, and note any discharge from Stensen duct.

Diagnostic Tests & Interpretation

Lab

Uncomplicated parotitis
- Mild leukopenia with lymphocytosis
Suppurative parotitis and mumps orchitis
- Leukocytosis
Pancreatic involvement
- Hyperamylasemia and elevated serum lipase
Salivary adenitis without pancreatic involvement
- Isolated hyperamylasemia
Gram stain and culture of pus expressed from Stensen duct is diagnostic in suppurative parotitis.
CDC lab criteria for mumps diagnosis
- Isolation of mumps virus from clinical specimens: blood, urine, buccal swab (Stensen duct exudates), throat washing, saliva, or CSF
- Detection of mumps virus nucleic acid by reverse transcriptase PCR
- Obtain specimens for culture and PCR as soon as possible after onset of symptoms, particularly in vaccinated individuals.
- Positive serologic test for mumps IgM
- Significant rise between acute and convalescent titers in mumps IgG levels by any standard assay (complement fixation, neutralization, hemagglutination inhibition, or enzyme immunoassays)
- For detailed information regarding collection and interpretation of laboratory studies and mumps case reporting, see http://www.cdc.gov/mumps/.

Alert
Mumps IgM may be negative in MMR-vaccinated individuals who develop mumps disease. A negative IgM test in these patients does not rule out mumps.
Alert
Paired acute and convalescent serum titers may not show a rise in IgG levels in MMR-vaccinated individuals with mumps disease.
Imaging
Sialography is useful to evaluate for stones or strictures but is contraindicated in acute infection.
Diagnostic Procedures/Other
Lumbar puncture if meningitis is suspected: CSF pleocytosis (predominately mononuclear)

Differential Diagnosis

Mumps parotitis can be distinguished from the other viral causes by clinical presentation along with specialized laboratory studies.
Cases of tuberculous and nontuberculous (atypical) mycobacterial parotitis are rare but have been reported.
Salivary calculus can be diagnosed by sialogram.
Recurrent childhood parotitis, also known as juvenile recurrent parotitis
- Rare, recurrent swelling of parotids
- Seen in children 3 " 6 years old
- Not associated with suppuration or external inflammatory changes
- Largely a diagnosis of exclusion
Cervical or preauricular adenitis
- May simulate parotitis
- Close anatomic localization should be diagnostic.
Infectious mononucleosis and cat-scratch disease are other considerations.
Drug-induced parotid enlargement occasionally occurs.
Malignancies of the parotid are extremely rare.
Sj Άgren syndrome is rare but reported in children.
Pneumoparotitis is seen in those with a history of playing a wind instrument, glass blowing, scuba diving, and even general anesthesia.

Treatment

General Measures

Supportive therapy is all that is required in mumps parotitis.
Antibiotics directed against S. aureus should be used in cases of suppurative parotitis.

Ongoing Care

Follow-up Recommendations

Most children have resolution of glandular swelling by ’ Ό1 week.
Disappearance of testicular pain and swelling can be expected 4 " 6 days after onset.
Testicular atrophy is common, although infertility is rare.
Markedly elevated pancreatic enzymes should be monitored until they improve.
Children should not return to school until at least 5 days after the onset of parotid swelling.
Isolation: standard precautions; droplet precautions for 5 days after onset of parotid swelling

Prognosis

Complete recovery in 1 " 2 weeks is the rule.

Complications

Meningitis
- >50% have a CSF pleocytosis.
- This "aseptic meningitis " is usually benign.
Encephalitis: rarely causes permanent sequelae
Cerebellitis
Facial nerve palsy
Oophoritis, nephritis, thyroiditis, myocarditis, mastitis, arthritis, transient ocular involvement, deafness, and sterility (all rare)

Additional Reading

American Academy of Pediatrics. Mumps. In: Pickering LK, ed. 2012 Red Book: Report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012:514 " 518.
Barskey AE, Schulte C, Rosen JB, et al. Mumps outbreak in Orthodox Jewish communities in the United States. N Engl J Med. 2012;367(18):1704 " 1713. [View Abstract]
Brauser D. Autism and MMR vaccine study: an "elaborate fraud, " charges BMJ. Medscape Web site. http://www.medscape.com/viewarticle/735354. Published January 6, 2011. Accessed March 11, 2015.
Centers for Disease Control and Prevention. Update: multistate outbreak of mumps " United States, Jan 1 " May 2, 2006. MMWR Morb Mortal Wkly Rep. 2006;55(20):559 " 563. [View Abstract]
Klein NP, Fireman B, Yih WK, et al. Measles-mumps-rubella-varicella combination vaccine and the risk of febrile seizures. Pediatrics. 2010;126(1):e1 " e8. [View Abstract]
Kutty PK, Kruszon-Moran DM, Dayan GH, et al. Seroprevalence of antibody to mumps virus in the US population, 1999 " 2004. J Infect Dis. 2010;202(5):667 " 674. [View Abstract]
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. [View Abstract]
Offit PA. Autism and the MMR vaccine, revisited. Medscape Web site. http://www.medscape.com/viewarticle/735439?src=ptalk. Published January 7, 2011. Accessed March 11, 2015.
Quinlisk MP. Mumps control today. J Infect Dis. 2010;202(5):655 " 656. doi:10.1086/655395. [View Abstract]
Senanayake SN. Mumps in the United States. N Engl J Med. 2008;359(6):654. [View Abstract]
Shacham R, Droma EB, London D, et al. Long-term experience with endoscopic diagnosis and treatment of juvenile recurrent parotitis. J Oral Maxillofac Surg. 2009;67(1):162 " 167. [View Abstract]
Virtanen M, Peltola H, Paunio M, et al. Day to day reactogenicity and the healthy vaccinee effect of measles-mumps-rubella vaccination. Pediatrics. 2000;106(5):E62. [View Abstract]

Codes

ICD09

072.9 Mumps without mention of complication
072.79 Other mumps with other specified complications
072.0 Mumps orchitis
072.3 Mumps pancreatitis
072.1 Mumps meningitis
072.2 Mumps encephalitis
072.71 Mumps hepatitis
072.72 Mumps polyneuropathy
072.8 Mumps with unspecified complication

ICD10

B26.9 Mumps without complication
B26.89 Other mumps complications
B26.0 Mumps orchitis
B26.3 Mumps pancreatitis
B26.2 Mumps encephalitis
B26.81 Mumps hepatitis
B26.84 Mumps polyneuropathy
B26.83 Mumps nephritis
B26.82 Mumps myocarditis
B26.85 Mumps arthritis
B26.1 Mumps meningitis

SNOMED

36989005 Mumps (disorder)
240526004 Mumps parotitis
78580004 mumps orchitis (disorder)
10665004 mumps pancreatitis (disorder)
63462008 mumps myocarditis (disorder)
17121006 Mumps nephritis (disorder)
44201003 Mumps meningitis (disorder)
31524007 mumps polyneuropathy (disorder)
31646008 Mumps encephalitis

FAQ

Q: Should immunization be deferred in children with intercurrent illness?
A: No. Children with minor illnesses, even with fever, should be vaccinated.
Q: Should vaccination be withheld in children living with immunocompromised hosts?
A: No. Vaccinated children do not transmit mumps vaccine virus.

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