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


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