Mumps


Article Author:
Patrick Davison


Article Editor:
Jason Morris


Editors In Chief:
Marie Amma
Jennifer Barrow
Darcy Duncan


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
11/21/2018 9:41:18 PM

Introduction

Mumps is a contagious viral illness and at one time was a very common childhood disease. With the implementation of widespread vaccination, the incidence of mumps in the population has decreased substantially. Mumps infection typically presents with a prodrome of headache, fever, fatigue, anorexia, malaise followed by the classic hallmark of the disease, parotitis. The disease is more often self-limited with individuals experiencing a full recovery.[1]

Etiology

Mumps is a single-stranded RNA paramyxovirus. There is only one known serotype of the mumps virus. Nucleoprotein, phosphoprotein, and polymerase together with the genomic RNA replicate the virus forming the ribonucleocapsid. A host-derived lipid bilayer surrounds the ribonucleocapsid. Within this lipid bilayer are viral neuraminidase and fusion proteins which allow cell binding and entry of the virus. These fusion complexes are the main targets of virus-neutralizing antibodies. The virus itself is a stable virus unable to combine. This makes antigenic shift unlikely.[2][3] This inability in genetic drift allows vaccination to most typically confer long-lasting immunity in individuals.[4]

Epidemiology

Mumps is endemic worldwide with epidemic outbreaks occurring approximately every five years in unvaccinated regions. The mumps virus is highly infectious and transmissible through direct contact with respiratory droplets, saliva, and household fomites. Up to one-third of individuals infected exhibit no symptoms, but are contagious. Introduction of the mumps vaccine in the year 1967 resulted in a 99.8% reduction of documented cases in the United States by 2001.[1] Several confounding factors caused recent outbreaks in the United Kingdom, Canada, and the United States during the early 2000s. A combination of waning vaccine immunity over time, the continuing global epidemic of mumps in non-vaccinated populations, and the absence of a wild-type virus to boost immune responses within vaccinated individuals. These factors coupled with individuals living in close quarters such as college dormitories allow the spread of a respiratory virus such as mumps to cause an outbreak.[5][1]

Pathophysiology

Humans are the only natural hosts for viral mumps. The virus has a variable incubation period of 7 to 21 days. Individuals are most contagious 1 to 2 days before the onset of symptoms. Primary replication occurs in upper airway mucosal epithelium. Infection of mononuclear cells in regional lymph nodes promotes viremia which leads to systemic inflammation in the salivary glands, testes, ovaries, pancreas, mammary glands, and the central nervous system (CNS).[6][7]

History and Physical

The prodrome of the mumps virus includes nonspecific symptoms such as fever, malaise, headache, myalgias, and anorexia shortly followed by parotitis in the following days. Mumps parotitis is the most common manifestation of the virus occurring in over 70% of infections. Parotid swelling is usually bilateral, but unilateral swelling can occur[1]. Parotid swelling presents as painful inflammation of the area between the earlobe and the angle of the mandible. The mucosa of Stenson’s duct is often red and swollen along with the involvement of the submaxillary and submandibular glands.[8][9] Glandular inflammation most often presents but then subsides within one week.[10] Recurrent sialadenitis is a frequent complication of parotitis. Mumps during pregnancy is unknown to lead to premature birth, low birth weight, or fetal malformation.[1][11][12][13][14] Orchitis is the next most common manifestation of mumps which leads to painful swelling, enlargement, and tenderness of the testes which is most often bilateral. Testicular atrophy develops in one half of those affected. Sterility and subfertility after mumps infection is rare and occurs in less than 15% of cases.[1][9][15][16][17] Oophoritis is also rare amongst infected females with less than 5% developing infertility or pre-menopause.[1] Neurological manifestations include meningitis, encephalitis, transverse myelitis, Guillan-Bare syndrome, cerebellar ataxia, facial palsy, and hydrocephalus. Neurological complications are typically self-resolving, and there is a low incidence of morbidity and mortality.[18] Additional systemic rare complications include pancreatitis, myocarditis, thyroiditis, nephritis, hepatic disease, arthritis, keratitis, and thrombocytopenic purpura.[19][20][21][22]

Evaluation

Clinical observation and laboratory testing confirm a mumps infection. Not all mumps cases classically display orchitis and parotitis and individuals may present heterogeneously. During an outbreak, the diagnosis is clinical in cases of parotid swelling with a history of exposure. When the local incidence is low other causes of parotitis warrant investigation. Laboratory testing is not routinely necessary to confirm a mumps viral infection, but in equivocal cases testing for other viral infections such as HIV, influenza, and para-influenza is necessary. Staphylococcus aureus is not an uncommon cause of suppurative parotitis. Recurrent parotid swelling of unknown etiology warrants an investigation for ductal calculi and malignancy. A viral mumps infection in the absence of parotid swelling and/or salivary gland involvement may present with symptoms of visceral and CNS predominance. In these cases, diagnosis relies on positive antibody titers and virus culture from oral secretions, urine, blood, and cerebrospinal fluid (CSF). Laboratory confirmation techniques include reverse transcriptase polymerase chain reaction (RT-PCR) and serum IgM antibodies. RT-PCR is for serum and oral secretions. RT-PCR specimens additionally are for viral cultures. At the initial presentation of an individual suspected of mumps infection collect 2 specimens: a buccal or oral swab for RT-PCR and also an acute phase serum specimen for IgM antibody, IgG antibody, and serum viral RT-PCR. Obtain oral specimens within three days of parotid gland swelling and no later than 8 days after the start of symptoms. The IgM response may not be detectable for up to five days after the onset of symptoms. Incorrect collection of acute-phase samples lead to false-negative IgM and RT-PCR tests. When this occurs collect repeat samples 5 to 10 days after symptom onset to yield positive results. Laboratory confirmation of an acute viral infection in individuals with prior vaccination is difficult. This occurs due to multiple reasons: IgM antibodies are negative in a large number of patients, and RT-PCR results may be falsely negative. The disease is a Center for Disease Control and Prevention (CDC) reportable illness with most states requiring reporting in 1 to 3 days.[23][6][7][10]

Treatment / Management

Mumps is typically a benign illness that is self-resolving. [1] Treatment is supportive care for each presenting symptom. Analgesic medications and cold or warm compresses for parotid swelling are beneficial. Treat testicular swelling and tenderness with elevation and cold compression.[24] There is no proven benefit for glucocorticoid use and surgical drainage of mumps parotitis and orchitis. Consider a therapeutic lumbar injection to relieve a headache associated with aseptic meningitis due to mumps viral infection.[25] Mumps immune-globulin (Ig) is not effective in preventing mumps and not recommend for treatment nor post-exposure prophylaxis in patients.[26] Common practice is to administer the mumps vaccine as part of a trivalent measles-mumps-rubella (MMR), commonly known as the abbreviated MMR vaccine. The vaccine is administered in 2 doses with children most often receiving the first dose around 1 year of age and the second dose typically given between the ages of 4 to 6. Immunity from mumps results from the development of neutralizing antibodies. Seroconversion occurs in most recipients, and post-vaccination immunity is around 80% after the first dose and 90% after the second dose. In 2018, the CDC recommended that individuals vaccinated prior with 2 doses of mumps vaccine are at increased for a population outbreak and should receive a third dose (for example, college students). [6][7][10][27][4][28] Prevention with vaccination is the most practical and effective control measure. The mumps vaccine is a live attenuated virus. It should not be administered to pregnant women and women should wait 4 weeks after MMR vaccination to become pregnant. Vaccinate women who are breastfeeding along with children and other household contacts of pregnant women. Individuals who suffered life-threatening allergic reactions to components of the vaccine or those with significant immunosuppression are not candidates for vaccination. This includes patients with AIDS, leukemia, lymphoma, generalized malignancy, and those receiving treatment with chemotherapy, radiation, or corticosteroid therapy. Vaccinate household contacts to those with severe immunosuppression. Do not vaccinate AIDS or HIV patients who have signs of immunosuppression, but vaccinate HIV patients who do not have laboratory evidence of immunosuppression.[4] Isolate patient infected with mumps and place on droplet precautions. The CDC recommends isolation for 5 days after the onset of parotid swelling.[7]

Enhancing Healthcare Team Outcomes

An Interprofessional Approach to Mumps

As practitioners in this era of the anti-vaccination movement, advocating the benefits of the MMR vaccine is vital. The resurgence of mumps outbreaks is preventable with proper patient education by practitioners from all spectrums of practice. Nurses, pharmacists, and other healthcare workers should repeatedly encourage parents to get their children vaccinated against mumps. While the infection is not life-threatening, it can have considerable morbidity if the testes or ovaries are affected.


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Mumps - Questions

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A patient presents with gradual malaise for 7 days. Examination reveals a problem with his face. Upward pressure on the angle of the mandible causes pain. What is the most likely diagnosis?



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Which of the following is not typical of mumps?



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Which of the following organisms commonly causes parotitis in children?



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Mumps virus has an affinity for which of the following central nervous system cells?



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Which of the following should not be given less than one month prior to conception?



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An 18-year-old has painful bilateral parotid enlargement and adenopathy in the neck. What is the most likely cause?



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A 13-year-old male develops fever, neck pain, malaise, and headache. He complains that drinking sour liquids increases the pain by his jaw. On exam, there is swelling and tenderness between the mandible and the mastoid with elevation of his earlobe. The skin is without abnormalities. His parents had refused immunizations because of concerns about autism. What is the most likely diagnosis?



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A 3-year-old male is brought in with unilateral swelling between the angle of the mandible and the mastoid process. Select the incorrect statement about this condition.



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A child is seen in the emergency department for mumps. Which of the following is true regarding this infection? Select all that apply.

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Attributed To: Contributed by The The Centers for Disease Control and Prevention, NIP, Barbara Rice (Public Domain)



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Which of the following are potential complications of mumps? Select all that apply.



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Mumps - References

References

Hviid A,Rubin S,Mühlemann K, Mumps. Lancet (London, England). 2008 Mar 15     [PubMed]
Watson JC,Hadler SC,Dykewicz CA,Reef S,Phillips L, Measles, mumps, and rubella--vaccine use and strategies for elimination of measles, rubella, and congenital rubella syndrome and control of mumps: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. Recommendations and reports : Morbidity and mortality weekly report. Recommendations and reports. 1998 May 22     [PubMed]
Hanna-Wakim R,Yasukawa LL,Sung P,Arvin AM,Gans HA, Immune responses to mumps vaccine in adults who were vaccinated in childhood. The Journal of infectious diseases. 2008 Jun 15     [PubMed]
Vandermeulen C,Clement F,Roelants M,Van Damme P,Hoppenbrouwers K,Leroux-Roels G, Evaluation of cellular immunity to mumps in vaccinated individuals with or without circulating antibodies up to 16 years after their last vaccination. The Journal of infectious diseases. 2009 May 15     [PubMed]
Mumps outbreak on a university campus--California, 2011. MMWR. Morbidity and mortality weekly report. 2012 Dec 7     [PubMed]
Exposure to mumps during air travel--United States, April 2006. MMWR. Morbidity and mortality weekly report. 2006 Apr 14     [PubMed]
Updated recommendations for isolation of persons with mumps. MMWR. Morbidity and mortality weekly report. 2008 Oct 10     [PubMed]
Foy HM,Cooney MK,Hall CE,Bor E,Maletzky AJ, Isolation of mumps virus from children with acute lower respiratory tract disease. American journal of epidemiology. 1971 Nov     [PubMed]
PHILIP RN,REINHARD KR,LACKMAN DB, Observations on a mumps epidemic in a virgin population. American journal of hygiene. 1959 Mar     [PubMed]
Kutty PK,Kyaw MH,Dayan GH,Brady MT,Bocchini JA,Reef SE,Bellini WJ,Seward JF, Guidance for isolation precautions for mumps in the United States: a review of the scientific basis for policy change. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2010 Jun 15     [PubMed]
Siegel M,Fuerst HT,Peress NS, Comparative fetal mortality in maternal virus diseases. A prospective study on rubella, measles, mumps, chicken pox and hepatitis. The New England journal of medicine. 1966 Apr 7     [PubMed]
Enders M,Rist B,Enders G, [Frequency of spontaneous abortion and premature birth after acute mumps infection in pregnancy]. Gynakologisch-geburtshilfliche Rundschau. 2005 Jan     [PubMed]
BOWERS D, Mumps during pregnancy. Western journal of surgery, obstetrics, and gynecology. 1953 Feb     [PubMed]
Siegel M, Congenital malformations following chickenpox, measles, mumps, and hepatitis. Results of a cohort study. JAMA. 1973 Dec 24     [PubMed]
Manson AL, Mumps orchitis. Urology. 1990 Oct     [PubMed]
Casella R,Leibundgut B,Lehmann K,Gasser TC, Mumps orchitis: report of a mini-epidemic. The Journal of urology. 1997 Dec     [PubMed]
Beard CM,Benson RC Jr,Kelalis PP,Elveback LR,Kurland LT, The incidence and outcome of mumps orchitis in Rochester, Minnesota, 1935 to 1974. Mayo Clinic proceedings. 1977 Jan     [PubMed]
RUSSELL RR,DONALD JC, The neurological complications of mumps. British medical journal. 1958 Jul 5     [PubMed]
Lin CY,Chen WP,Chiang H, Mumps associated with nephritis. Child nephrology and urology. 1990     [PubMed]
Roberts WC,Fox SM 3rd, Mumps of the heart. Clinical and pathologic features. Circulation. 1965 Sep     [PubMed]
Gordon SC,Lauter CB, Mumps arthritis: a review of the literature. Reviews of infectious diseases. 1984 May-Jun     [PubMed]
Hung W, Mumps thyroiditis and hypothyroidism. The Journal of pediatrics. 1969 Apr     [PubMed]
UTZ JP,HOUK VN,ALLING DW, CLINICAL AND LABORATORY STUDIES OF MUMPS. The New England journal of medicine. 1964 Jun 11     [PubMed]
MCLEAN DM,BACH RD,LARKE RP,MCNAUGHTON GA, MUMPS MENINGOENCEPHALITIS, TORONTO, 1963. Canadian Medical Association journal. 1964 Feb 15     [PubMed]
Trojian TH,Lishnak TS,Heiman D, Epididymitis and orchitis: an overview. American family physician. 2009 Apr 1     [PubMed]
Glikmann G,Pedersen M,Mordhorst CH, Detection of specific immunoglobulin M to mumps virus in serum and cerebrospinal fluid samples from patients with acute mumps infection, using an antibody-capture enzyme immunoassay. Acta pathologica, microbiologica, et immunologica Scandinavica. Section C, Immunology. 1986 Aug     [PubMed]
Briss PA,Fehrs LJ,Parker RA,Wright PF,Sannella EC,Hutcheson RH,Schaffner W, Sustained transmission of mumps in a highly vaccinated population: assessment of primary vaccine failure and waning vaccine-induced immunity. The Journal of infectious diseases. 1994 Jan     [PubMed]
Cardemil CV,Dahl RM,James L,Wannemuehler K,Gary HE,Shah M,Marin M,Riley J,Feikin DR,Patel M,Quinlisk P, Effectiveness of a Third Dose of MMR Vaccine for Mumps Outbreak Control. The New England journal of medicine. 2017 Sep 7     [PubMed]

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