A 23-year-old student presents with three days of swelling in his cheeks, more on his right than left. He complains of fevers, chills, malaise, headache, and decreased oral intake. He is a Russian immigrant, and unsure of his complete vaccination status. When asked to sit in a comfortable position, this is what you see.
What condition are you concerned about, and how would you treat it? Continued on p. 35.
Mumps is a highly contagious, self-limited, viral infection that causes painful swelling of the salivary glands. Humans serve as the only natural host for this single-stranded RNA paramyxovirus. Infection is spread by respiratory droplets, direct close contact, or fomites. (BMJ 2005;330:1132.) The incubation period is approximately 12 to 24 days, and can infect an unvaccinated person of any age (it is most common in ages 2 to 12, and rare in children under 1 because of maternal antibody transmission).
Prior to widespread vaccine use, mumps was the most common cause of viral meningitis and unilateral acquired deafness in children, with outbreaks typically in late winter and early spring. (Clin Infect Dis 2008;47:1458.)
In 1967 a live, attenuated mumps vaccine was introduced, and it decreased infection rates by 95 percent to 99 percent. (MMWR CDC Surveill Summ 1995;44:1.) A single vaccine is no longer available in the United States, but is part of the combined live MMR vaccine that includes measles, mumps, and rubella +/− varicella (MMRV). Initially a single dose of vaccine was recommended, but between 1989 and 1991, despite widespread vaccination programs, outbreaks of mumps in high schools, colleges, military quarters, summer camps, and hospitals were reported in previously vaccinated individuals.
Immunity does appear to improve with re-dosing, which the CDC recommends for school-aged children (K-12) and high-risk adults (health care or daycare workers, international travelers to endemic areas, and college students) who only received one dose. A first dose at 12 to 15 months and a second dose at ages 4 to 6 years is currently considered the standard. (MMWR 2006;55:629.) Patients with a history of anaphylactic reaction to MMR/MMRV, pregnant women, immunocompromised individuals (including those on chronic steroid therapy) should not be given the (live) vaccine. The World Health Organization also has mumps vaccination guidelines (http://bit.ly/WHOmumps), but mumps-associated complications and deaths are still common in developing countries.
The classic description of an acute mumps infection is fever, headache, anorexia, malaise, myalgias, and referred ear pain followed by bilateral face pain and swelling (90% of cases) of the parotid glands (Nurs Times 2005;101:53) in more than 60 percent of infections but 95 percent of symptomatic patients (Lancet 2008;371:932) within 48 hours of symptom onset. Other salivary glands are involved in 10 percent of cases. (http://bit.ly/MumpsVaccine.) Subclinical infections, typically nonspecific respiratory infections, can occur, and are more likely in children.
A clinical diagnosis is often sufficient if the patient has a classic bilateral parotitis infection. Numerous viral and bacterial pathogens can cause parotitis, especially in the immunocompromised patient. Noninfectious etiologies of parotitis also include malignancy, salivary duct stone with secondary infection, and autoimmune conditions (Sjögren's syndrome). If laboratory testing is obtained, an elevated serum amylase is common. Depending on the organs involved, the mumps virus may be isolated from saliva, cerebrospinal fluid, or urine by polymerase chain reaction testing.
There is no specific treatment for mumps other than supportive care, including local application of ice or heat packs, hydration, analgesics and antipyretics, soft mechanical diet, and warm salt water gargles if needed. After infection, the patient is immunized for life.
Secondary mumps infection can occur in multiple organ systems resulting in viral meningitis (most common is nonsalivary gland complication in up to 10% of cases), deafness, pancreatitis, oophoritis (7% post-pubertal girls), and rarely encephalitis, labyrinthitis, Bell's palsy, Guillain-Barré syndrome, transverse myelitis, thyroiditis, myocarditis, interstitial nephritis, fetal death, and mono and polyarticular arthritis. These complications may occur without preceding parotids, and make the diagnosis of mumps associated complications challenging. Orchitis, sudden onset of fever, testicular mass and pain, and scrotal swelling [bilateral 30%]) are the most common complications in post-pubescent males (38%). (Urology 1990;36:355.) Infertility (rare) and compromised fertility (10%-13%) are of concern for male patients who develop orchitis. (Medicine [Baltimore] 2010;89:96; J Urol 1997;158:2158.) Some have suggested a link between previous mumps orchitis infection and the subsequent development of testicular cancer (Br J Cancer 1987;55:97), but a causal link has yet to be proven, and is controversial. (Urologe A 1980;19:283.)
The most significant viral shedding and contagious period is typically three days before symptom onset. (MMWR 2006;55:401.) Current guidelines recommend patient isolation for five days after symptom onset because viral shedding can occur for days. (MMWR 2008;57:1103.) Vaccination is recommended for close contacts with no symptoms or only one dose of vaccine in the past. (www.CDC.org.) Although this does not prevent acute infection, it is recommended as a public health measure. There is no evidence of secondary transmission, so the vaccine can be administered to susceptible household members and health care workers with immunosuppressed patient contact. (Infect Control Hosp Epidemiol 2007;28:702.)
This patient was admitted to the ED observation unit for intravenous fluid hydration, and had an uneventful course.
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