eMedicine Specialties > Emergency Medicine > Infectious Diseases

Mumps

Author: Kristin A Carmody, MD, Assistant Professor, Boston University Medical School; Attending Physician, Department of Emergency Medicine and Associate Director of Emergency Ultrasound, Boston Medical Center
Coauthor(s): Richard H Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center
Contributor Information and Disclosures

Updated: Mar 23, 2009

Introduction

Background

Mumps is a systemic illness caused by the paramyxovirus. It is a human disease that occurs worldwide. The mumps vaccine was introduced in 1967, and the disease became nationally reportable in 1968. The incidence has decreased substantially with vaccination, but periods of resurgence have occurred in recent years.¹

Please see the following immunization guidelines, adult immunization schedule²  and recommendations for immunization³  from the Advisory Committee on Immunization Practices.

Pathophysiology

The mumps virus is transmitted by respiratory droplets. It has an incubation period of 14-25 days after which time prodromal symptoms occur and last anywhere from 3-5 days. After the prodrome, the symptoms of the virus depend on which organ is affected. The most common presentation is a parotitis, which occurs in 30-40% of patients. Other reported sites of infection are the testes, pancreas, eyes, ovaries, central nervous system, joints, and kidneys. A patient is considered infectious from about 3 days before the onset and up to 4 days after the start of active parotitis. Infections can be asymptomatic in up to 20% of persons.

Frequency

United States

Prior to the vaccine about 50% of children contracted mumps. Approximately 200,000 cases were reported in 1964 before the introduction of the vaccine compared with 291 cases in 2005. A resurgence occurred in 1986 and 1987, with almost 13,000 cases reported, and it was associated with a lack of state requirements for immunizations. These cases were mostly in older school-aged children (10-19 y). In the 1990s, 30-40% of cases reported each year were in persons aged 15 years or older as opposed to 90% being younger than 15 years old in earlier years.⁴

A recent outbreak of mumps occurred in Iowa, with 219 cases reported in 2006. In addition, another 14 cases of people with symptoms consistent with the virus were reported in nearby states (Illinois, Nebraska, and Minnesota). This is the largest number of cases reported in the United States since 1988. The median age of the 219 persons was 21 years, with 30% being college students. In 1991, Iowa mandated that 2 doses of mumps vaccine be required for all people entering public schools. Vaccination history was studied in 133 people from this outbreak: 65% (87) of the patients had received 2 doses, 14% (19) had received only 1 dose, and 6% (8) received no vaccine at all.⁵

Amongst the infected, the most commonly reported symptoms were parotitis (83%), submaxillary/submandibular gland swelling (40%), fever (36%), and sore throat (32%). The average length of illness was 5.1 days. Complications, including encephalitis and orchitis, were reported in 5% of patients. The source of the Iowa epidemic is unknown.⁵

International

The variations in the number of persons who receive the mumps vaccination worldwide make it difficult to estimate the numbers affected. The incidence varies markedly from region to region.

The United Kingdom reported an epidemic of mumps in 2005, with 56,390 cases reported in persons aged 15-24 years who were not vaccinated.⁴

Mortality/Morbidity

Between 1980 and 1999, an average of one death per year has occurred due to mumps. Most deaths occur in persons older than 19 years.

• CNS involvement is common, but symptomatic meningitis only occurs in about 15% of patients. It usually resolves without complications, but adults are at a higher risk for sequelae. Encephalitis is rare and is seen in fewer than 2 per 100,000 cases. It has a mortality rate of 1.4%.^6,7,8,9
• Orchitis can occur in 50% of postpubertal males. It causes testicular atrophy in as many as 50% of persons affected but rarely causes sterility.^7,10
• Pancreatitis occurs in 5% of persons infected with mumps. The hyperglycemia that results is usually transient, but a few cases of diabetes mellitus have been reported. It is not conclusive that the mumps virus has been the definitive cause.⁷
• Deafness has been reported in 1 per 20,000 cases of mumps. In 80% of cases, the hearing loss is reported to be unilateral.^11,12
• Some deaths due to myocarditis have been reported. The incidence of this complication is reported to be up to 15%, but it is usually asymptomatic.¹³
• The risk of spontaneous abortion is increased in a woman who contracts mumps in the first trimester.
• Other complications reported are chronic arthritis, arthralgias, and nephritis.¹³

Sex

• For parotitis, males and females are affected equally.
• Symptomatic meningitis has a male-to-female ratio of 3:1.

Age

Before the mumps vaccine was introduced, most cases were in children aged 5-9 years, with 90% being younger than 15 years. The resurgence in the late 1980s affected older children aged 10-19 years. In more recent years, up to 30-40% of cases have been in persons older than 15 years.¹

Clinical

History

• After the incubation period, mumps usually has a prodromal phase, which consists of nonspecific viral symptoms: low-grade fever, malaise, myalgias, and headache.
• The prodromal phase is usually followed by unilateral or bilateral parotid gland swelling. This usually occurs within the first 2 days of infection.
• Infections can be asymptomatic in up to 20% of persons.
• Patients typically complain of worsening pain when eating or drinking acidic foods.
• Persons can present with other symptoms without a preceding parotitis.
  • CNS presentations can include headache, neck pain, and fever. Preceding parotitis can be absent in up to 50% of these persons.^11,6,8,9
  • Orchitis can occur in up to 50% of postpubertal males, and as many as 30% have bilateral involvement. Sterility is rare.^10,7
  • Patients can present with abdominal pain due to oophoritis or pancreatitis. Oophoritis occurs in up to 5% of postpubertal females.
  • Sudden hearing loss may occur due to a vestibular reaction.¹¹
  • Other rare presenting symptoms can be due to arthralgias, arthritis, mastitis, thyroiditis, thrombocytopenic purpura, or nephritis.

Physical

• Low-grade fever is common with mumps.
• Usually, parotid gland swelling that is not warm or erythematous is present.
• The swollen parotid gland may lift the earlobe upward and outward.
• The patient may complain of an earache and have tenderness over the angle of the mandible.
• Opening of Stensen duct can be edematous and erythematous.
• The patient may have trismus.
• Submandibular and sublingual glands may also be involved and swollen.
• A morbilliform rash may be present.

Causes

• Mumps is typically caused by the paramyxovirus.
• Other viruses implicated in recurrent parotitis are influenza, echovirus, parainfluenza (types 1 and 3), and coxsackievirus A. More rare causes of parotitis seen in persons with HIV infection are adenovirus or cytomegalovirus.
• Bacterial (suppurative) parotitis is most commonly caused by Staphylococcus aureus infection.
• The largest risk factor is lack of immunization or rarely in children who have only received the first vaccination at 15 months.

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