eMedicine Specialties > Emergency Medicine > Infectious Diseases

Mumps

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
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

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.

Differential Diagnoses

Other Problems to Be Considered

Bacterial (suppurative) parotitis
Parotid duct stone
Drug reactions
Parotid tumor
Cervical lymphadenitis
Cytomegalovirus
Mikulicz syndrome

Workup

Laboratory Studies

• Diagnosis is usually clinical. Laboratory evaluation is usually undertaken in the ED to look for other causes of a patient's symptoms or to evaluate for complications or comorbidity. Mumps-specific tests are generally performed on an outpatient basis.
• Mumps virus can be isolated from nasopharyngeal swabs, urine, blood, and fluid from buccal cavity typically from 7 days before up until 9 days after the onset of parotitis.
• Mumps infection can be confirmed by demonstrating significant rise in mumps specific immunoglobulin G (IgG) antibody between acute and convalescent titers or a positive mumps immunoglobulin M (IgM). IgG titer can be detected by complement fixation, hemaglutination inhibition, or enzyme immunoassay.
• Polymerase chain reaction (PCR) can be used to detect viral antigen.
• A lymphocytosis or leukopenia may be present.
• Serum amylase level may be elevated.
• CNS infections usually exhibit a lymphocytic pleocytosis.

Imaging Studies

• No specific imaging studies are diagnostic.
• Imaging studies may be needed as a further workup with certain complications of mumps.
• Testicular ultrasonography may be performed when acute orchitis is found clinically, with specific indication to rule out torsion.

Treatment

Prehospital Care

• Supportive care is usually all that is needed for patients with mumps.
• Persons exposed to the virus should be counseled on vaccination and risks.

Emergency Department Care

• Supportive care and outpatient follow up is indicated for straightforward infections.
• Complications due to mumps should be treated based on presentation.
  • Testicular ultrasonography for orchitis
  • Ice packs applied to scrotal area for swelling
  • Discharge with scrotal support and anti-inflammatory agents
  • Intravenous hydration for severe pancreatitis
  • Lumbar puncture for symptomatic meningitis or encephalitis

Consultations

Consultations should be requested as needed for specific complications.

Medication

Treatment of bacterial parotitis should be directed against S aureus.

Antibiotics

For suppurative parotitis when S aureus is the pathogen.

Amoxicillin and clavulanate (Augmentin)

Drug combination treats bacteria resistant to beta-lactam antibiotics.

Dosing

Adult

500 mg PO q12h or 250 mg PO q8h

Pediatric

45 mg/kg/d PO divided bid/tid; not to exceed 750-1500 mg/d
Children >3 months: Base dosing protocol on amoxicillin content; due to different amoxicillin/clavulanic acid ratios in 250-mg tab (250/125) vs 250-mg chewable tab (250/62.5), do not use 250-mg tab until child weighs >40 kg

Interactions

Coadministration with warfarin or heparin increases risk of bleeding

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Give for a minimum of 10 d to eliminate organism and prevent sequelae (endocarditis, and rheumatic fever); following treatment, perform cultures to confirm eradication of streptococci

Cefadroxil (Duricef)

First generation semisynthetic cephalosporin that arrests bacterial cell wall synthesis, inhibiting bacterial growth. Used for skin and soft tissue infections caused by S aureus.

Dosing

Adult

1-2 g/d PO divided bid

Pediatric

30 mg/kg PO divided bid; not to exceed 2 g/d

Interactions

Probenecid may decrease clearance of cephalosporins; aminoglycosides and furosemide may decrease nephrotoxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe renal impairment; prolonged use may result in superinfection

Clindamycin (Cleocin)

Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes causing RNA-dependent protein synthesis to arrest.

Dosing

Adult

150-450 mg/dose PO q6-8h; not to exceed 1.8 g/d

Pediatric

8-20 mg/kg/d PO as hydrochloride or 8-25 mg/kg/d as palmitate divided tid/qid

Interactions

Increases duration of neuromuscular blockade, induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin

Contraindications

Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic associated colitis

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficile

Follow-up

Further Inpatient Care

• Patients with specific complications may require further inpatient care.
• Persons with encephalitis, meningitis, nephritis, myocarditis, or severe pancreatitis require more supportive care.

Further Outpatient Care

• Classic mumps with no major complications can be managed on an outpatient basis with supportive care and good follow up.
• Scrotal support, ice, and analgesia
• Hearing tests in young children

Transfer

• Transfer is rarely needed. Indication to transfer would be if major complications are present and current hospital does not have appropriate services to treat the patient appropriately.

Deterrence/Prevention

• Vaccination remains the best protection. The Centers for Disease Control and Prevention posts the latest immunization schedules on their Web site.
• Isolate persons who have virus while hospitalized.

Complications

• Meningoencephalitis: Although most patients recover without prolonged sequela, the mortality rate has been reported to be up to 1.4%.⁹
• Orchitis: This is the most common complication in the pediatric population. This does not usually result in sterility. Ultrasonography may be indicated when orchitis is clinically identified to rule out torsion.
• Oophoritis
• Pancreatitis
• Transverse myelitis
• Cerebellar ataxia
• Myocarditis
• Sensorineural hearing loss
• Additional rare complications include nephritis, arthritis, thrombocytopenic purpura, mastitis, thyroiditis, and keratouveitis.

Prognosis

• Prognosis for mumps infection is usually good.
• The most serious complication is encephalitis, with a mortality rate of 1.4%.
• Orchitis can cause sterility if bilateral.
• Transient sensorineural loss occurs in 4% of adults.

Patient Education

• For excellent patient education resources, visit eMedicine's Bacterial and Viral Infections Center. Also, see eMedicine's patient education article Mumps.

Miscellaneous

Medicolegal Pitfalls

• Medicolegal pitfalls relate more to the complications of mumps such as CNS or orchitis.

References

1. Caplan CE. Mumps in the era of vaccines. CMAJ. Mar 23 1999;160(6):865-6. [Medline].

2. Recommended adult immunization schedule - United States, 2009. National Guideline Clearinghouse. Available at http://www.guideline.gov/summary/summary.aspx?doc_id=13982&nbr=007058&string=mumps. Accessed March 23, 2009.

3. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). Update: recommendations from the Advisory Committee on Immunization Practices (ACIP) regarding administration of combination MMRV vaccine. National Guideline Clearinghouse. Available at http://www.guideline.gov/summary/summary.aspx?doc_id=12325&nbr=006390&string=mumps. Accessed March 23, 2009.

4. Global status of mumps immunization and surveillance. Wkly Epidemiol Rec. Dec 2 2005;80(48):418-24. [Medline].

5. CDC; MMWR Weekly. Mumps Epidemic - Iowa, 2006. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5513a3.htm. Accessed September 29, 2008.

6. Majda-Stanislawska E. Mumps cerebellitis. Eur Neurol. 2000;43(2):117. [Medline].

7. Nussinovitch M, Volovitz B, Varsano I. Complications of mumps requiring hospitalization in children. Eur J Pediatr. Sep 1995;154(9):732-4. [Medline].

8. Saijo M, Fujita K. [Central nervous system infection caused by mumps virus]. Nippon Rinsho. Apr 1997;55(4):870-5. [Medline].

9. Sonmez FM, Odemis E, Ahmetoglu A, Ayvaz A. Brainstem encephalitis and acute disseminated encephalomyelitis following mumps. Pediatr Neurol. Feb 2004;30(2):132-4. [Medline].

10. Wharton IP, Chaudhry AH, French ME. A case of mumps epididymitis. Lancet. Feb 25 2006;367(9511):702. [Medline].

11. Kayan A, Bellman H. Bilateral sensorineural hearing loss due to mumps. Br J Clin Pract. Dec 1990;44(12):757-9. [Medline].

12. McQuone SJ. Acute viral and bacterial infections of the salivary glands. Otolaryngol Clin North Am. Oct 1999;32(5):793-811. [Medline].

13. Kabakus N, Aydinoglu H, Yekeler H. Fatal mumps nephritis and myocarditis. J Trop Pediatr. Dec 1999;45(6):358-60. [Medline].

Keywords

mumps, mumps virus, mumps vaccine, parotitis, swollen cheeks, epidemic parotiditis, measles-mumps-rubella vaccine, MMR vaccine, vaccination, shots, paramyxovirus, meningitis, CNS involvement in mumps, orchitis, deafness, pancreatitis

Contributor Information and Disclosures

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
Kristin A Carmody, MD is a member of the following medical societies: American College of Emergency Physicians, American Institute of Ultrasound in Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

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
Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Robert M McNamara, MD, FAAEM, Chair and Professor, Department of Emergency Medicine, Temple University School of Medicine
Robert M McNamara, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Association, Pennsylvania Medical Society, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Jeter (Jay) Pritchard Taylor III, MD, Compliance Officer, Attending Physician, Emergency Medicine Residency, Department of Emergency Medicine, Palmetto Health Richland, University of South Carolina; Medical Director, Department of Emergency Medicine, Palmetto Health Baptist
Jeter (Jay) Pritchard Taylor III, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

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