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
- 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.
- 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.
- 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).
- 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.
- 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
- Mild inflammation is common.
- Serious involvement is rare.
- Prodromal symptoms uncommon but may include the following:
- Onset usually pain and swelling in front of and below ear
- 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.
- 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.
- 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
- 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)
- 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.
- Supportive therapy is all that is required in mumps parotitis.
- Antibiotics directed against S. aureus should be used in cases of suppurative parotitis.
- 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
Complete recovery in 1 to 2 weeks is the rule.
- >50% have a CSF pleocytosis.
- This “aseptic meningitis” is usually benign.
- Encephalitis: rarely causes permanent sequelae
- Facial nerve palsy
- Oophoritis, nephritis, thyroiditis, myocarditis, mastitis, arthritis, transient ocular involvement, deafness, and sterility (all rare)
- 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]
- 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.
- 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]
- 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]
- 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]
- 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]
- 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]
- 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]
- Quinlisk MP. Mumps control today. J Infect Dis. 2010;202(5):655–656. doi:10.1086/655395. [PMID:20662719]
- Senanayake SN. Mumps in the United States. N Engl J Med. 2008;359(6):654. [PMID:18687651]
- 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
- 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
- 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
- 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.
Camille Sabella, MD
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