Mumps/Parotitis

Mumps/Parotitis: Excerpt from The 5-Minute Pediatric Consult

Nicholas Tsarouhas, MD

Mumps/Parotitis - BASICS

Mumps/Parotitis - description

CDC clinical case definition: 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.

Mumps/Parotitis - general prevention

• A single 0.5-mL SC injection of live mumps vaccine (usually given together with measles and rubella, the MMR) at 12–15 months usually confers long-lasting immunity.
• A second vaccination is recommended between 4 and 6 years of age.
• Primary vaccine failure and waning vaccine-induced immunity have been reported.
• The 1st dose of MMR vaccine sometimes causes fever and rash, usually 7–10 days after immunization:
  • Measles component is usually the culprit.
• Links of the MMR vaccine to autism have not been substantiated.
• Vaccine should not be administered to children who are immunocompromised by disease or pharmacotherapy or to pregnant women.
• Children with HIV infection who are not severely immunocompromised should be immunized with the MMR vaccine.
• 1 attack of mumps (clinical or subclinical) confers lifelong immunity.

Mumps/Parotitis - epidemiology

Mumps/Parotitis - incidence

• Incidence of this once very common disease has declined dramatically since the advent of universal childhood immunization. Outbreaks, however, continue to occur.
• Since 2001, 200–300 cases per year reported in the US.
• 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 to CDC and American College Health Association to recommend 2 doses of MMR be a requirement for college entry.

Mumps/Parotitis - pathophysiology

• The virus is spread by contact with respiratory secretions.
• The mumps virus enters via the respiratory tract, and a viremia ultimately ensues.
• The viremia 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: 1–2 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.

Mumps/Parotitis - etiology

• Parotitis is usually caused by mumps, a Rubulavirus in the paramyxovirus family.
• Other viral causes of parotitis include cytomegaloviruses, influenza, parainfluenza, and enteroviruses.
• Bacterial cases are usually secondary to Staphylococcus aureus (suppurative parotitis):
  • Streptococci, Gram-negative bacilli, and anaerobic infections are also possible.
• Recurrent parotitis is an idiopathic, rare, recurrent swelling of the parotids, without suppuration or external inflammatory changes.
• Rare childhood cases may be secondary to an obstructing calculus, foreign body (sesame seed), or various drugs (antihistamines, phenothiazines, iodine-containing drugs/contrast media).

Mumps/Parotitis - associated conditions

• Salivary adenitis:
  • Most common manifestation of mumps, although 1/3 of cases occur subclinically
• Epididymo-orchitis:
  • 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.
• Pancreatitis:
  • Mild inflammation is common; serious involvement is rare.

Mumps/Parotitis - DIAGNOSIS

Mumps/Parotitis - signs & symptoms

• 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, usually begin ~1 week after the parotid swelling of mumps.
• 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.
• Parotid enlargement can be an initial sign in HIV-infected children.

Mumps/Parotitis - physical exam

• Nonerythematous, tender parotid swelling (erythema seen with suppurative parotitis)
• Swelling ultimately obscures the mandibular ramus.
• The ear is often displaced upward and outward.
• 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 - tests

Caution:

• Skin tests should not be used for test of immunity; serologic studies are more reliable.

Mumps/Parotitis - 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 specimen, or
  • Significant rise between acute and convalescent titers in mumps IgG levels by any standard assay (complement fixation, neutralization, hemagglutination inhibition, or enzyme immunoassays), or
  • Positive serologic test for mumps IgM

Mumps/Parotitis - imaging

Sialography is useful to evaluate for stones or strictures, but is contraindicated in acute infection.

Mumps/Parotitis - diag proced-surgery

Lumbar puncture if meningitis is suspected:

• CSF pleocytosis (predominately mononuclear)

Mumps/Parotitis - differencial 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 is a rare disorder in which symptoms initially manifest in children 3–6 years of age:
  • Largely a diagnosis of exclusion.
• Cervical or preauricular adenitis may simulate parotitis:
  • Close anatomic localization should be diagnostic.
• Infectious mononucleosis and catscratch disease are other considerations.
• Drug-induced parotid enlargement occasionally occurs.
• Malignancies of the parotid are extremely rare.
• Pneumoparotitis is seen in those with a history of playing a wind instrument, glass blowing, scuba diving, and even general anesthesia.

Mumps/Parotitis - TREATMENT

Mumps/Parotitis - 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.

Mumps/Parotitis - FOLLOW UP

• Most children have resolution of glandular swelling by ~1 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 9 days after the onset of parotid swelling.

Mumps/Parotitis - prognosis

Complete recovery in 1–2 weeks is the rule.

Mumps/Parotitis - 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)

Mumps/Parotitis - bibliography

American Academy of Pediatrics. Mumps. In: Pickering LK, ed. 2006 Red Book: Report of the Committee on Infectious Diseases. 27th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2006:464–466.Casella R, Leibundgut B, Lehman K, et al. Mumps orchitis: Report of a mini-epidemic. J Urol. 1997;158:2158–2161.CDC. Mumps epidemic—Iowa, 2006. MMWR. 2006;55:366–368.CDC. Update: Multistate Outbreak of Mumps—United States, Jan 1-May 2, 2006. MMWR. 2006;55:559–563.Chitre VV, Premchandra DJ. Recurrent parotitis. Arch Dis Child. 1997;77:359–363.Elliman D, Bedford H. MMR vaccine: The continuing saga. BMJ. 2001;332:183–184.Galazka AM, Robertson SE, Kraigher A. Mumps and mumps vaccine: A global review. Bull WHO. 1999;77:3–14.Gemmill IM. Mumps vaccine: Is it time to re-evaluate our approach? Can Med Assoc J. 2006;175:491–492.Taylor B, Miller E, Farrington CP, et al. Autism and measles, mumps, and rubella vaccine: No epidemiologic evidence for a causal association. Lancet. 1999;353:2026–2029.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.Watson JC, Hadler SC, Dykewicz CA, et al. Measles, mumps, and rubella—vaccine use and strategies for elimination of measles, mumps, rubella, and congenital rubella syndrome and control of mumps. MMWR. 1998;47:1–57.

Mumps/Parotitis - CODES

Mumps/Parotitis - icd9

• 072 Mumps
• 072.9 Mumps without complications

Mumps/Parotitis - 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.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

More About Parotitis

• Back to disease: Parotitis: Introduction
• Next Book Extract About Parotitis: Surveys relating to Parotitis
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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