Type your tag names separated by a space and hit enter

Mumps/Parotitis

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

  • 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, and cases in the United States have ranged from several hundred to several thousand cases annually.
  • Since 2014, >1,000 cases per year have been reported in the United States, with >6,000 cases reported in 2016.
  • Most outbreaks have been linked to being in a close crowded environment and intense exposures, such as universities, sports teams, and close-knit religious communities.
  • Outbreaks can occur in highly vaccinated communities, particularly in very close-contact settings such as college dormitories and camps.
  • High vaccination rate helps limit the severity, size, and duration of mumps outbreaks.

General Prevention

  • Two 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 to 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.
  • During mumps outbreaks, a third dose of vaccine may be recommended by public health authorities for targeted populations in conjunction with CDC guidance. Studies indicate no increase in adverse effects after a third vaccine dose and improved control of mumps outbreak.
  • The first dose of MMR vaccine can be associated with fever and rash:
    • These symptoms occur 7 to 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 to 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 (IG), administration of MMR vaccine should be delayed (for 3 to 11 months depending on the dose of immune globulin).
  • Children with HIV infection who are not severely immunocompromised (age-specific CD4+ T-lymphocyte percentages of 15% or greater) should be immunized with the MMR vaccine.
  • One attack of mumps (clinical or subclinical) usually confers lifelong immunity.
  • Links of the MMR vaccine to autism by Andrew Wakefield in a 1998 Lancet publication have now been exposed as fraudulent, and multiple studies have documented no association between MMR vaccine and autism.

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, Sjögren syndrome, or various drugs (antihistamines, phenothiazines, iodine-containing drugs/contrast media).

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 to 3 days before to 5 days after onset of parotid swelling
  • Incubation period: 12 to 25 days after exposure (16 to 18 days most common)
  • Humans are the only known host for mumps.

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 to 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 suggests 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.
    • These may manifest only with upper respiratory tract symptoms.
  • 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.

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 to 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.
  • Sjögren 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.

Diagnostic Tests and Interpretation

  • 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/.
  • Sialography is useful to evaluate for stones or strictures but is contraindicated in acute infection.
  • Lumbar puncture if meningitis is suspected: CSF pleocytosis (predominately mononuclear)
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.
  • Paired acute and convalescent serum titers may not show a rise in IgG levels in MMR-vaccinated individuals with mumps disease.

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 ~1 week.
  • Disappearance of testicular pain and swelling can be expected 4 to 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 to 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

  1. Albertson JP, Clegg WJ, Reid HD, et al. Mumps Outbreak at a University and Recommendation for a Third Dose of Measles-Mumps-Rubella Vaccine—Illinois, 2015–2016. MMWR Morb Mortal Wkly Rep. 2016;65(29):731–734.  [PMID:27467572]
  2. American Academy of Pediatrics. Mumps. In: Kimberlin DW, Brady MT, Jackson MA, et al, eds. Red Book: 2015 Report of the Committee on Infectious Diseases. American Academy of Pediatrics; 2015:564–568.
  3. 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.  [PMID:23113481]
  4. Cardemil CV, Dahl RM, James L, et al. Effectiveness of a third dose of MMR vaccine for mumps outbreak control. N Engl J Med. 2017;377(10):947–956.  [PMID:28877026]
  5. Dayan GH, Quinlisk MP, Parker AA, et al. Recent resurgence of mumps in the United States. N Engl J Med. 2008;358(15):1580–1589.  [PMID:18403766]
  6. Klein NP, Fireman B, Yih WK, et al; for Vaccine Safety Datalink. Measles-mumps-rubella-varicella combination vaccine and the risk of febrile seizures. Pediatrics. 2010;126(1):e1–e8.  [PMID:20587679]
  7. McLean HQ, Fiebelkorn AP, Temte JL, et al; for Centers for Disease Control and Prevention. Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: summary recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2013;62(RR-04):1–34.  [PMID:23760231]
  8. Ogbuanu IU, Kutty PK, Hudson JM, et al. Impact of a third dose of measles-mumps-rubella vaccine on a mumps outbreak. Pediatrics. 2012;130(6):e1567–e1574.  [PMID:23129075]
  9. Quinlisk MP. Mumps control today. J Infect Dis. 2010;202(5):655–656. doi:10.1086/655395.  [PMID:20662719]
  10. Senanayake SN. Mumps in the United States. N Engl J Med. 2008;359(6):654.  [PMID:18687651]

Codes

ICD-9

  • 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

ICD-10

  • 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.
  • Q: Is immune globulin effective in controlling mumps outbreaks?
  • A: No. Postexposure prophylaxis for mumps with immune globulin is not effective.

Authors

Camille Sabella, MD


© Wolters Kluwer Health Lippincott Williams & Wilkins

Mumps/Parotitis is a sample topic from the 5-Minute Pediatric Consult.

To view other topics, please or purchase a subscription.

Pediatrics Central™ is an all-in-one application that puts valuable medical information, via your mobile device or the web, in the hands of clinicians treating infants, children, and adolescents. Learn more.

Citation

Cabana, Michael D., editor. "Mumps/Parotitis." 5-Minute Pediatric Consult, 8th ed., Wolters Kluwer, 2019. Pediatrics Central, peds.unboundmedicine.com/pedscentral/view/5-Minute-Pediatric-Consult/617498/all/Mumps_Parotitis.
Mumps/Parotitis. In: Cabana MD, ed. 5-Minute Pediatric Consult. 8th ed. Wolters Kluwer; 2019. https://peds.unboundmedicine.com/pedscentral/view/5-Minute-Pediatric-Consult/617498/all/Mumps_Parotitis. Accessed April 21, 2019.
Mumps/Parotitis. (2019). In Cabana, M. D. (Ed.), 5-Minute Pediatric Consult. Available from https://peds.unboundmedicine.com/pedscentral/view/5-Minute-Pediatric-Consult/617498/all/Mumps_Parotitis
Mumps/Parotitis [Internet]. In: Cabana MD, editors. 5-Minute Pediatric Consult. Wolters Kluwer; 2019. [cited 2019 April 21]. Available from: https://peds.unboundmedicine.com/pedscentral/view/5-Minute-Pediatric-Consult/617498/all/Mumps_Parotitis.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Mumps/Parotitis ID - 617498 ED - Cabana,Michael D, BT - 5-Minute Pediatric Consult UR - https://peds.unboundmedicine.com/pedscentral/view/5-Minute-Pediatric-Consult/617498/all/Mumps_Parotitis PB - Wolters Kluwer ET - 8 DB - Pediatrics Central DP - Unbound Medicine ER -