eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Mumps

Eileen C Quintana, MD, Assistant Professor, Departments of Pediatrics and Emergency Medicine, St Christopher's Hospital for Children
Hosseinali Shahidi, MD, MPH, Assistant Professor, Departments of Emergency Medicine and Pediatrics, State University of New York and Health Science Center at Brooklyn

Updated: Jul 9, 2009

Introduction

Background

The mumps virus is a paramyxovirus that shares various epidemiological characteristics with other well-known viral pediatric diseases, such as measles and rubella. The disease is distributed worldwide, and paramyxovirus is highly infectious to nonimmune individuals.

During the 2003 epidemic of severe acute respiratory syndrome (SARS), it was thought that the SARS-causing virus belonged to the Paramyxoviridae family. However, current case criteria have determined that SARS follows the clinical, laboratory, and transmission characteristics of a coronavirus named SARS-associated coronavirus (SARS-CoV) and not specifically to the mumps virus.^1,2

Humans are the sole reservoir for the mumps virus, and the transmission mode is person to person via respiratory droplets and saliva.

Mumps is caused by a specific virus with only one antigenic type known. It contains a single-stranded, negative-sense RNA surrounded by an envelope. One of the 2 glycoproteins on the surface of the envelope mediates neuraminidase and hemagglutinating activity, whereas the other is responsible for lipid membrane fusion to the host cell.

Even though it shares morphologic features of parainfluenza virus type 2, no cross-immunity between the 2 viruses is apparent.

Pathophysiology

After the initial entry into the respiratory system, the virus replicates locally, then follows with a viremic dissemination to target tissues, such as the central nervous system (CNS) and salivary glands, particularly the parotid glands. This fact was a significant contribution from an experimentally induced mumps infection by Henly et al in 1948.

A secondary phase of viremia, found before the immune response, is the result of replication of the virus at the target organs. Viruria is common, via blood transmission of the virus into the kidneys, where active replication occurs. Therefore, impairment of renal function may occur.

Cell necrosis and inflammation with mononuclear cell infiltration is the tissue response. Salivary glands show edema and desquamation of necrotic epithelial cell lining the ducts. Focal hemorrhage and destruction of germinal epithelium may occur, leading to duct plugging.

Frequency

United States

The incidence of mumps, which is more common in the winter and spring, has markedly declined since the introduction of the mumps vaccine. In 1967, when the live-attenuated mumps virus vaccine was introduced in the United States, 185,691 cases occurred. While a minor resurgence of mumps occurred from 1986-1987, in 1991, 4000 cases were reported.³ Generally, the incidence is between 500-1500 yearly; however, another mumps resurgence has been noted in the central United States in 2006. This resurgence in a single year has occurred in college students aged 18-25 years.⁴

Mortality/Morbidity

Death due to mumps is rare; more than one half of the fatalities occur in persons older than 19 years.

Unilateral hearing loss is associated with mumps infection. This devastating complication is rare.

For those who develop meningoencephalitis, the mortality rate is 2%.⁵

• Approximately 10% of all infected patients develop a mild form of meningitis, which could be confused with bacterial meningitis. Encephalitis, transient myelitis, or polyneuritis is rare.
• Orchitis occurs in 10-20% of patients. Subsequent sterility is rare, and oophoritis is quite rare and is usually a benign inflammation of the ovaries.
• Other rare complications include myocarditis, nephritis, arthritis, thyroiditis, pancreatitis, thrombocytopenia purpura, mastitis, and pneumonia. These usually resolve within 2-3 weeks without sequelae.

Sex

• No sex predilection exists.
• For meningoencephalitis, males are affected 3-5 times more often than females.

Age

Incidence rates are currently highest in those aged 5-9 years, followed by those aged 1-4 years, then those aged 10-14 years.

Clinical

History

• The incubation period of mumps virus is an average of 16-18 days (in approximately 30-40% of patients), with a range of 12-29 days.
• The period of communicability is usually from 9 days prior to the onset of parotid edema to 1-2 days after onset of swelling and occasionally lasting as long as 7 days after swelling.
• Symptoms include fever, headache, and malaise.
• Within 24 hours, patients usually complain of ear pain, which is localized near the lobe of the ear and aggravated by a chewing movement of the jaw.
• Fever usually subsides after a variable period of up to 1 week and well before the salivary gland edema disappears.

Physical

• The clinical manifestations appear to be a direct result of virus spread to other sites, which illustrates the extensive tissue tropism of mumps.
• After the initial presentation of fever, headache, and earache, the parotid gland enlarges and rapidly progresses to maximum size in 1-3 days.
  • As the edema progresses, the lobe of the ear is displaced upward and outward.
  • Pain and tenderness may be intense during this period, and symptoms rapidly subside after swelling reaches its peak. The parotid gland gradually decreases in size in 3-7 days. Commonly, one parotid gland swells before the other. Only 25% of patients with mumps have bilateral parotitis. Stensen duct opening may be erythematous and edematous.
  • Sublingual gland involvement, most commonly bilateral, is considered the least common manifestation of mumps. The sublingual gland is palpated on the floor of the mouth and submental area. In severe and extensive cases, the edema may extend to the presternal area due to an obstruction of the lymphatic vessels by the compression of the enlarged salivary glands.
  • Submaxillary gland edema, palpable underneath and anterior to the angle of the mandible, may be accompanied by edema spreading onto the cheek and downward onto the neck. If parotitis does not simultaneously occur, it is difficult to differentiate from cervical adenitis. Wharton duct opening may be erythematous and edematous.
• Epididymo-orchitis is the second most common manifestation of adult mumps, which is usually preceded by parotitis. Unilateral involvement is found in 20-30% of the patients, whereas bilateral involvement occurs in fewer than 2% of cases.⁶
  • Orchitis presents acutely with fever, chills, nausea, vomiting, and lower abdominal pain. After the fever, the testes begin to rapidly swell. The size increase could be slight or as much as 4 times normal size. As the fever decreases, the pain and edema subside. Loss of turgor is noticed with as many as 50% of cases demonstrating atrophy. Absolute sterility sequela is rare, with impairment of fertility found in 13% of patients.
  • Oophoritis is associated with pelvic pain and tenderness. It is noted in 7% of postpubertal females. Impairment of fertility is not evident.
• Meningoencephalitis is the most frequent complication in childhood. The true incidence is difficult to determine because of the subclinical infection of the CNS, but clinical findings have been reported in as many as 10% of cases. The mortality rate is 2%, with males being affected 3-5 times more often than females.
  • The pathogenesis is described as a primary infection of the neurons and/or postinfection encephalitis with demyelination.
  • Parotitis may appear simultaneously with the primary neuron infection, or it may appear 10 days after the parotitis in the postinfection type.
  • The illness presents with fever, headache, nausea, vomiting, nuchal rigidity, and change of sensorium. Mumps is a common cause of aseptic meningitis, which usually is indistinguishable from other causes, such as enteroviruses and herpes or pox viruses. The cerebrospinal fluid (CSF) has less than 500 cells/mm³, mostly lymphocytes. Mumps virus can be isolated in the CSF.
• Pancreatitis is a severe but, fortunately, rare manifestation. A sudden onset of epigastric pain and tenderness occurs accompanied by fever, chills, nausea, and vomiting. Elevated amylase level is found with mumps regardless of the presence of pancreatitis. Lipase is a more specific indicator of pancreatic involvement, and measurements of it should be obtained. After 1 week, the patient generally completely recovers.
• A diffuse tender swelling of the thyroid gland may occur about 1 week after parotitis, with the development of antithyroid antibodies.
• Myocarditis is a serious and extremely rare manifestation. The only reported ECG findings are depression of ST segments and bradycardia in 13% of adults with myocarditis.
• Mastitis is uncommon in either sex.
• Unilateral deafness, permanent or transient, has a low incidence (1:15,000), but mumps is the leading cause of deafness.⁷
• Ocular manifestations include dacryadenitis, optic neuritis, uveokeratitis, scleritis, and central vein thrombosis.
• Arthralgia is associated with erythema and edema of the joint; recovery is complete.
• Thrombocytopenia purpura may be present (infrequent).

Causes

Mumps is caused by a paramyxovirus that has one antigenic type. It contains a single-stranded, negative-sense RNA surrounded by an envelope.

Differential Diagnoses

Pediatrics, Chicken Pox or Varicella
Pediatrics, Measles
Pediatrics, Meningitis and Encephalitis
Pediatrics, Pertussis
Pediatrics, Roseola Infantum
Pediatrics, Rubella

Other Problems to Be Considered

Suppurative or recurrent parotitis
Parotid calculus
Coxsackievirus infection
Parainfluenza type 3 infection
Mixed tumors, hemangiomas, lymphangiomas of the parotid gland
Mikulicz syndrome
Uveoparotid fever
Human immunodeficiency virus (HIV) infection
Meningoencephalitis
Allergic reaction, rare

Workup

Laboratory Studies

• Generally, no laboratory studies are needed if the ED presentation is typical for mumps.
• Mumps virus can be isolated in a cell culture inoculated with throat washings, urine, or spinal fluid.
• Serum amylase level is elevated in mumps parotitis and pancreatitis. Serum lipase level is elevated in pancreatitis.
• The complete blood count (CBC) may be elevated with a predominance of lymphocytes. In mumps orchitis, an elevated serum C-reactive protein level may be found.⁸

Imaging Studies

• If considering meningoencephalitis, head CT, precontrast, prior to lumbar puncture, should be considered.

Other Tests

• The complement fixation (CF), neutralization, or hemagglutination inhibition (HAI) test or an enzyme immunoassay (EIA) can be used to serologically confirm infection or vaccination.

Procedures

• If considering meningoencephalitis, perform a lumbar puncture to eliminate causes other than mumps.

Treatment

Emergency Department Care

• A live-virus vaccine should be subcutaneously administered, in the form of the combination MMR (mumps, measles, rubella) vaccination. Antibodies develop in 95% of all susceptible persons after a single dose.^9,10,11
  • MMR vaccine should be given routinely to children aged 12-15 months. A second dose of MMR vaccine is recommended for those aged 4-6 years in accordance with recommendations for routine measles vaccination. If this dose is missed, it should be given before age 12 years.
  • Revaccination is indicated because mumps can occur in highly vaccinated populations. MMR vaccine is not harmful if given to a patient already immune to one or more of the other viruses.
  • Mumps vaccination is imperative to patients approaching adolescence and adulthood. Persons should be considered susceptible unless they have documentation of at least 1 dose of vaccine on or after the first birthday, documentation of physician-diagnosed mumps, serologic evidence of immunity, or birth date before 1957. Vaccination should be offered before traveling even though it is not a requirement of entry to many countries.
  • Precautions and contraindications to vaccination include the following: Children with minor illnesses with or without fever can be vaccinated. Allergic reactions to vaccination occasionally occur but tend to be minor. Most children with egg sensitivity can be safely vaccinated. Skin testing with MMR vaccine does not reliably predict which children will have a hypersensitivity reaction.
  • Live mumps vaccine should be given 2 weeks before or 3 months after administration of immunoglobulin or blood transfusion because of the theoretical possibility that the antibody will neutralize the vaccine virus and inhibit a successful immunization.
  • Patients with immunodeficiencies (eg, those on large doses of steroids, radiation, or chemotherapy) should not receive live-virus vaccine. The exceptions are patients with symptomatic HIV who are not severely immunocompromised; these patients should receive MMR vaccine. Vaccinating close susceptible contacts can reduce the risk of exposure for patients with altered immunity.
  • Vaccines should not be administered during pregnancy.
• Standard immune globulin is ineffective against mumps.

Medication

The goal of pharmacotherapy is to immunize the child.

Vaccines

Vaccines are used to induce active immunity.

Measles, mumps, and rubella vaccine combination (M-M-R II)

Used to induce immunity against viruses that cause measles, mumps, and rubella.

Dosing

Adult

0.5 mL SC in outer aspect of upper arm
Birth date before 1957: Considered to be immune to measles and mumps, no further MMR vaccination required
Birth date during 1957 or later: Should receive 2 doses at least 4 wk apart unless they have a medical contraindication, documentation of 2 doses, history of confirmed measles infection, or laboratory evidence of immunity
Second dose recommended for the following adults: (1) those who have been recently exposed to measles or mumps in an outbreak setting, particularly if in their age group; (2) those who have been previously vaccinated with killed measles vaccine; (3) those who have been vaccinated with an unknown type of measles vaccine during 1963–1967; (4) those who are students in postsecondary educational institutions; (5) those who work in a health care facility; and (6) those who plan to travel internationally
Unreliable rubella vaccination history: Administer 1 dose
Unvaccinated health care workers born before 1957: If no evidence of mumps immunity; administer 1 dose; strongly consider a second dose during an outbreak situation

Pediatric

First dose: 0.5 mL SC initiated at age >12 months
Second dose: 0.5 mL at age 4-6 y; may be administered before age 4-6 y, provided >4 wk have elapsed since the first dose
Catch up doses: If not previously vaccinated by age 6 years, administer 2 doses of 0.5 mL SC with >4 wk between doses

Interactions

Drugs that suppress immune system may diminish response to immunization

Contraindications

Documented hypersensitivity; cancer affecting bone marrow or lymphatic systems, blood dyscrasias, HIV, or other severe immunosuppressive condition; pregnant women or women who might become pregnant within 4 wk of receiving vaccine

Precautions

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Contraception in females is advised for 3 mo following immunization; not indicated for severely immunocompromised patients; determine rubella immunity for women of childbearing years and counsel regarding congenital rubella syndrome

Follow-up

Further Inpatient Care

• Admit patients with mumps to the pediatric floor if signs of toxicity or dehydration are present.

Further Outpatient Care

• Arrange for a follow-up visit with the primary care physician within 1-2 days.

Deterrence/Prevention

• Droplet precautions are recommended until 9 days after the onset of parotid swelling.
  • Children should be excluded from school and childcare centers for 9 days from the onset of parotid gland swelling.
  • If outbreaks occur in the school or childcare center, all should be vaccinated.
  • Those who have been exempted from vaccination for medical, religious, or other reasons should be excluded from school or day care until at least 26 days after the onset of parotitis in the last person with mumps in the affected school.

Complications

• Hearing loss
• Meningitis/encephalitis
• Orchitis
• Oophoritis
• Pancreatitis
• Transient myelitis
• Polyneuritis
• Myocarditis
• Nephritis
• Arthritis
• Thyroiditis
• Thrombocytopenia purpura
• Mastitis
• Pneumonia

Prognosis

• Most patients completely recover.

Patient Education

• For excellent patient education resources, visit eMedicine's Common Childhood Illnesses Center, Children's Health Center, and Bacterial and Viral Infections Center. Also, see eMedicine's patient education articles Mumps and Immunization Schedule, Children.

Miscellaneous

Medicolegal Pitfalls

• Failure to consider the highly infectious nature of the disease (eg, protection of others, removal from day care)
• In 2007, after a review of evidence, the American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention (CDC) changed their recommendation from 9-day isolation guidance (standard precautions and droplets precautions) to 5 days after the onset of parotitis.¹²
• Failure to consider other sources if the patient presents with meningoencephalitis

Special Concerns

• Lifelong immunity usually follows clinical or subclinical infection, although second infections have been documented.
• Transplacental antibodies seem effective in protecting infants during their first 6-8 months of life.
• Infants born to mothers who have mumps in the week prior to delivery may have clinically apparent mumps at birth or develop illness in the neonatal period.
• The severity ranges from mild parotitis to severe pancreatitis.
• The serum neutralization test is the most reliable method for determining immunity.

References

1. CDC. Revised U.S. surveillance case definition for severe acute respiratory syndrome (SARS) and update on SARS cases--United States and worldwide, December 2003. MMWR Morb Mortal Wkly Rep. Dec 12 2003;52(49):1202-6. [Medline].

2. MMWR Morb Mortal Wkly Rep. Severe acute respiratory syndrome (SARS) and coronavirus testing--United States, 2003. MMWR Morb Mortal Wkly Rep. Apr 11 2003;52(14):297-302. [Medline].

3. Dobson R. Mumps cases rise among teenagers and young adults. BMJ. Jul 17 2004;329(7458):132. [Medline].

4. Kancherla VS, Hanson IC. Mumps resurgence in the United States. J Allergy Clin Immunol. Oct 2006;118(4):938-41. [Medline].

5. Koskiniemi M, Donner M, Pettay O. Clinical appearance and outcome in mumps encephalitis in children. Acta Paediatr Scand. Jul 1983;72(4):603-9. [Medline].

6. Committee on Infectious Diseases, American Academy of Pediatrics. Report of the Committee on Infectious Diseases. In: Red Book. 2003:439-443.

7. Hashimoto H, Fujioka M, Kinumaki H. An office-based prospective study of deafness in mumps. Pediatr Infect Dis J. Mar 2009;28(3):173-5. [Medline].

8. Niizuma T, Terada K, Kosaka Y, Daimon Y, Inoue M, Ogita S, et al. Elevated serum C-reactive protein in mumps orchitis. Pediatr Infect Dis J. Oct 2004;23(10):971. [Medline].

9. [Guideline] Averhoff FM, Williams WW, Hadler SC. Immunization of adolescents: recommendations of the Advisory Committee on Immunization Practices, the American Academy of Pediatrics, the American Academy of Family Physicians, and the American Medical Association. J Sch Health. Sep 1997;67(7):298-303. [Medline].

10. CDC Immunization Schedules. Last updated March 2009. United States Centers for Disease Control and Prevention. Available at http://www.cdc.gov/vaccines/recs/schedules/default.htm.

11. MMWR Morb Mortal Wkly Rep. Recommended immunization schedules for persons aged 0 through 18 years --United States, 2009. MMWR Morb Mortal Wkly Rep. Jan 2 2009;57(51):[Full Text].

12. [Guideline] CDC. Updated recommendations for isolation of persons with mumps. MMWR Morb Mortal Wkly Rep. Oct 10 2008;57(40):1103-5. [Medline].

13. Gilgen-Anner Y, Heim M, Ledermann HP, Bircher AJ. Iodide mumps after contrast media imaging: a rare adverse effect to iodine. Ann Allergy Asthma Immunol. Jul 2007;99(1):93-8. [Medline].

14. Gold E. Almost extinct diseases: measles, mumps, rubella, and pertussis. Pediatr Rev. Apr 1996;17(4):120-7. [Medline].

15. Hinman A. Eradication of vaccine-preventable diseases. Annu Rev Public Health. 1999;20:211-29. [Medline].

16. MMWR Morb Mortal Wkly Rep. Status report on the Childhood Immunization Initiative: reported cases of selected vaccine-preventable diseases--United States, 1996. MMWR Morb Mortal Wkly Rep. Jul 25 1997;46(29):665-71. [Medline].

17. Phillips C, Behrman RE, Vaughan VC, eds. Mumps. In: Nelson's Textbook of Pediatrics. 13^th ed. 1987:673-5.

18. Sherris JC, Ryan KJ, eds. Mumps. In: Medical Microbiology: An Introduction to Infectious Diseases. 2^nd ed. 1994:517-9.

Keywords

mumps, mumps virus, MMR, parotitis, epidemic parotiditis, measles-mumps-rubella vaccine, MMR vaccine, paramyxovirus, viremia, viruria, viral pediatric disease, live-attenuated mumps virus vaccine, meningoencephalitis, parotid gland enlargement

Contributor Information and Disclosures

Author

Eileen C Quintana, MD, Assistant Professor, Departments of Pediatrics and Emergency Medicine, St Christopher's Hospital for Children
Eileen C Quintana, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Hosseinali Shahidi, MD, MPH, Assistant Professor, Departments of Emergency Medicine and Pediatrics, State University of New York and Health Science Center at Brooklyn
Hosseinali Shahidi, MD, MPH is a member of the following medical societies: American Academy of Pediatrics, American College of Emergency Physicians, and American Public Health Association
Disclosure: Nothing to disclose.

Medical Editor

Garry Wilkes, MBBS, FACEM, Director of Emergency Medicine, Bunbury Hospital, Western Australia; Medical Director, St John Ambulance, WA Ambulance Service; Adjunct Associate Professor, Edith Cowan University; Clinical Associate Professor, Rural Clinical School, University of Western Australia, Australia.
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Grace M Young, MD, Associate Professor, Department of Pediatrics, University of Maryland Medical Center
Grace M Young, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Emergency Physicians
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

Richard G Bachur, MD, Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston
Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research
Disclosure: Nothing to disclose.

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