Mumps

definition ,cause ,presentation ,diagnosis ,treatment ,prevention ,vaccination

1. Mumps
Prof. Dr. Saad S Al Ani
Senior Pediatric consultant
Head of Pediatric Department
Khorfakkan hospital
Sharjah .UAE
[email protected]

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khorfakkan Hospital
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Definition
Mumps is an acute viral infectionof
childhood that typically involves swelling of
one or both parotid glands, although many
different organs can be infected.
Centers for Disease Control and Prevention :Updated recommendations of the Advisory Committee on Immunization
Practices (ACIP) for the Control and Elimination of Mumps. Morbid Mortal Wkly Rep MMWR2006;55:366-368

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khorfakkan Hospital
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Etiology
Mumps virus, the cause of mumps, is an
RNA virusof the genusRubulavirusin
the Paramyxoviridaefamily, which also
includes the parainfluenza viruses. Only
one serotypeis known
1.Johansson B,Tecle T,Orvell C:Proposed criteria for classification of new
genotypes of mumps virus. Scand J Infect Dis2002;34:355.
2. Palacios G,Jabado O,Cisterna D,et al:Molecular identification of mumps
virus genotypes from clinical samples: standardized method
of analysis. J Clin Microbiol2005;43:1869

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Epidemiology
Mumps isendemicin most unvaccinated
populations
The virus is spreadfrom human reservoir by;
* Direct contact
* Airborne droplets
* Fomitescontaminated by saliva
* possibly byurine
It is distributed worldwide
Affects both sexes equally

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Epidemiology (cont.)
Beforeintroduction of the vaccine in 1967:
* the peak incidenceof the disease occurred in
children 5-9 yrof age
* 85%of infections occurred in children younger
than 15 yr of age.
Nowmost cases occur in young adults,
producing outbreaks in colleges or in the
workplace.

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khorfakkan Hospital
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Epidemiology (cont.)
Outbreaksappear to be primarily related
to a lack of immunization, especially in an
underimmunized cohort of children born
from 1967-1977, rather than to waning to
immunity.
Epidemicsoccur at all seasonsbut are
slightly more frequentin late winter and
spring.

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khorfakkan Hospital
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Epidemiology (cont.)
In the United States, the reported
incidence of mumps declined after the
introduction of mumps vaccine in 1967
the recommendation for its routine use in
1977.
After expanded recommendations for a 2-
dosemeasles, mumps, and rubella (MMR)
vaccine schedule for measles controlin
1989, mumps cases declined further

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khorfakkan Hospital
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Reported cases of mumps infection per 100 000 population, 1978–2003. (Data from Centers for
Disease Control and Prevention. Summary of notifiable diseases, United States 2003. MMWR
2005;52: 54.)

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khorfakkan Hospital
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Number of reported cases of mumps by year –United States, 1980–2006. Data for
2005 and 2006 are provisional. MMR, measles, mumps, and rubella.

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khorfakkan Hospital
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Epidemiology (cont.)
Virushas been isolated from salivaas long as 6
days beforeand up to 9 days afterappearance
of salivary gland swelling.
Transmissiondoes not seem to occurmore
than 24 hr beforethe appearance of the swelling
orlater than 3 days afterit has subsided.
Virus has been isolated from urinefrom the 1st-
14th day afterthe onset of salivary gland
swelling.

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Pathogenesis
Afterentry into the last and initial
multiplication in the cells of the respiratory
tract, the virus is bloodborneto many
tissues, among which the salivaryand
other glandsare the most susceptible.

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khorfakkan Hospital
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Clinical Manifestations
The incubation periodranges from 14-24 days, with a
peakat 17-18 days.
Approximately 30-40%of infections are subclinical
In children, prodromal manifestationsare rarebut may
be manifest by:
* Fever
* Muscular pain(especially in the neck)
* Headache
*Malaise
typically precedethe parotid swelling by 12 to 24 hours

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Clinical Manifestations (cont.)
*Common complaintsare:
Earacheon the side of parotid
involvement
Discomfortwith eating or drinking acidic
food
*Parotid painis most pronounced duringthe
first few days of swelling

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Clinical Manifestations (cont.)
The swollen parotid gland lifts the earlobe
upward and outward, and the angle of the
mandible is obscured
the openingof the Stensen ducton the
buccal mucosa is edematousand
erythematous.
Trismus (spasm of the masticatory
muscles) can occur.

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khorfakkan Hospital
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Toddler with mumps parotitis
(Courtesy of A. Margileth.)

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Clinical Manifestations (cont.)
Other salivary glands such as the
submandibularand sublingual glandsmay
also be involved.
In 10-15%of patients onlythe
submandibular gland(s)may be swollen
Presternal edemacan be notable.
Morbilliform rashhas been reported in
association with mumps infection

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Clinical Manifestations (cont.)
Systemic symptoms, including fever,
usually resolvewithin 3 to 5 days
the parotid swellingsubsideswithin 7 to
10 days
Adolescents and adultshave more severe
disease than young children.
Kathleen M.Gutierrez . Mumps Virus. In : Long: Principles and Practice of Pediatric Infectious Diseases, CHAPTER 224, 3rd ed.

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Diagnosis
The diagnosis of mumps parotitis is usually
apparentfrom the clinical symptomsand physical
examination
Routine laboratory testsare nonspecific; usually
leukopeniais present with relative lymphocytosis.
An elevationin serum amylaselevels is common;
the rise tends to parallel the parotid swellingand
then to return to normal within 2 wk

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Diagnosis (cont.)
The microbiologic diagnosis is by serology
or virus culture
Enzyme immunoassayfor mumps
immunoglobulin(Ig).
IgGand IgMantibodies are most commonly
used for diagnosis.
IgM antibodiesare detectable in the first
few days of illnessand are considered
diagnostic

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Diagnosis (cont.)
Mumps virus can be cultured fromthe
saliva, cerebrospinal fluid, blood, urine,
brain, and other infected tissues.
Primary cultures of human or monkey
kidney cells are used for viral isolation
The mumps skin testis unreliablefor
diagnosis of mumps and for determination
of susceptibility to infection.

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DIFFERENTIAL DIAGNOSIS
The differential diagnosis of parotitis is broad and includes:
bacterial (suppurative) parotitis
parotid duct stone
drug reactions
recurrent parotitis of childhood
Other viruses, such as influenza, coxsackievirus A,
echovirus, and parainfluenza viruses 1 and3, can cause
parotitis and are usually responsible for “recurrent
mumps”
parotid tumor
Sjögren syndrome

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Boy with parotitis not due to mumps
virus. (Courtesy of J.H. Brien.)

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khorfakkan Hospital
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Treatment
There is no specific antiviral therapy;
treatment is entirely supportive.
Antipyretics(acetaminophen or ibuprofen)
are indicated for fever.
Bed restshould be guided by the patient's
needs, but no evidence indicates that it
prevents complications. The diet should be
adjusted to the patient's ability to chew.

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Treatment (cont.)
Orchitis should be treated with local
supportand bed rest.
Mumps arthritismay respond to a 2-wk
courseof a nonsteroidal anti-inflammatory
agent or corticosteroids.
Salicylates do not appear to be effective

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Complications
MENINGOENCEPHALOMYELITIS
1.The most frequent complicationin childhood
2. Clinical manifestationsoccur in more than
10%of patients
3. The incidenceof mumps meningoencephalitis
is approximately 250/ 100,000 cases
4. The mortality rateis about 2%

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Complications
MENINGOENCEPHALOMYELITIS (cont.)
5. may be either:
I. Primary infectionof neurons:
parotitisfrequently appears at the same
time or followingthe onset of encephalitis
II. Postinfectious encephalitiswith
demyelination :
encephalitisfollowsparotitisby an
average of10 days.

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Complications
MENINGOENCEPHALOMYELITIS (cont.)
*Mumps meningoencephalitis is clinically
indistinguishable from meningoencephalitis of
other origins
* Moderate stiffness of the neckis seen, but the
remainingfindings on neurologic examination are
usually normal
*The cerebrospinal fluidmay show a lymphocytic
pleocytosis of less than 500 cells/ mm3, although
occasionally the count may exceed 2,000 cells/mm3.

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Complications (cont.)
ORCHITIS AND EPIDIDYMITIS
1.These complications rarely occurin prepubescent
boys but are common(14-35%) in adolescents
and adults.
2. The testisis most often infected with or without
epididymitis; epididymitismay also occur alone.
3. Bilateral orchitisoccurs in approximately 30%of
patients. Rarely, there is a hydrocele.
4.The orchitis usually follows parotitiswithin 8 days.
Orchitis may also occur withoutevidence of
salivary gland infection. .

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Complications
ORCHITIS AND EPIDIDYMITIS (cont.)
5.The onsetis usually abrupt, with a rise in
temperature, chills, headache, nausea, and
lower abdominal pain;
6.The affected testisbecomes tenderand
swollen, and the adjacent skin is edematous
and red.
7.The average durationof illness is 4 days.
8. Approximately 30-40%of affected testes atrophy,
leaving a cosmetic imbalance.
9. Infertilityis rareeven with bilateral orchitis.

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Complications (cont.)
OOPHORITIS
Pelvic painand tendernessare noted in
about 7%of postpubertal femalepatients.
There is noevidence of impairment of
fertility.

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Complications (cont.)
PANCREATITIS
* Mild or subclinicalpancreatic involvement is common, but
severepancreatitis is rare.
* It may be unassociatedwith salivary gland manifestations
and may be misdiagnosed as gastroenteritis.
* Epigastric painand tenderness, which are
suggestive, may be accompanied by
fever, chills, vomiting, and prostration.
* An elevated serum amylasevalue is characteristically
present in patients with mumps, with or without clinical
manifestations of pancreatitis

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Complications (cont.)
MYOCARDITIS
*Seriouscardiac manifestations are extremely
rare
* mildinfection of the myocardium may be more
common than is recognized.
* Electrocardiographic tracings revealed changes, mostly
depression of the ST segment, in 13% of adults in one
series.
* Such involvement may explain the precordial pain,
bradycardia, and fatiguesometimes noted among
adolescents and adults with mumps.

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Complications (cont.)
ARTHRITIS
* Migratory polyarthralgiaand even arthritisare
occasionally seen in adults with mumps but are
rare in children.
* The knees, ankles, shoulders, and wrists are
most commonly affected.
* The symptoms last from a few days to 3 mo,
with a median duration of 2 wk

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Complications (cont.)
THYROIDITIS
* It is uncommon in children
* A diffuse, tender swelling of the thyroid
may occur about 1 wk after the onset of
parotitis
* Antithyroid antibodiessubsequently
develop

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khorfakkan Hospital
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Complications (cont.)
DEAFNESS
* Unilateral, rarely bilateral, nerve
deafness may occur
* the incidenceis low(1/15,000 cases)
* mumps was historicallya leading cause
of unilateral nerve deafness.
* The hearing loss may be transientor
permanent.

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Complications (cont.)
OCULAR COMPLICATIONS
* Dacryoadenitismay occur with painful
swelling, usually bilateral, of the lacrimal
glands.
* Optic neuritis(papillitis) may occur
* Symptoms varyfrom loss of vision to mild
blurring, with recoveryin 10-20 days.

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Prognosis
The prognosis of mumps in childhood is
excellent.
Infection usually confers permanent
immunity
Reinfectionshave been documented

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Prevention
Mumps vaccine is derived from the Jeryl Lynn strainof
mumps virus,
The vaccine induces antibodyin 96%of seronegative
recipients and has 97%protective efficacy.
The initial mumps immunization, usually as measles-
mumps-rubella (MMR) vaccine, is recommended at 12-
15 mo of age.
A second immunization, also as MMR, is recommended
routinely at 4-6 yr of agebut may be administered at any
time during childhood provided at least 4 wk have
elapsed since the first dose.

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Prevention (cont.)
Women should avoid becoming pregnantfor 30 days
after monovalent mumps vaccination(3 mo if vaccination
was performed with rubella vaccine).
Other contraindicationsto vaccination include:
* allergy to a vaccine component (anaphylaxis to
neomycin)
* moderate or severe acute illnesses with or without
fever
* immunodeficiency (primary immunodeficiencies,
cancer and cancer therapy, long-term high-dose
corticosteroid therapy, severely immunocompromised,
including those with HIV infection)
* recent immune globulin administration

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Prevention (cont.)
Children who have not previously received
the second doseshould be immunizedby
11-12 yr of age.
Rarely, parotitis and low-grade fevercan
develop 10-14 days aftervaccination.
Vaccinees do not shed virus.
Maternal antibodyis protectivein the
infant in the first 6 mo of life.

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Key Changes in 2006 Recommendations
for Mumps Vaccine
ACCEPTABLE PRESUMPTIVE EVIDENCE OF
IMMUNITY
Documentation of adequate vaccination is now 2 doses
of a live mumps virus vaccineinstead of 1 dose for:
school-aged children(i.e., grades K–12).
adults at high risk(i.e., persons who work in
healthcare facilities, international travelers, and students
at posthigh-school educational facilities)
Centers for Disease Control and Prevention. Updated recommendations of the
Advisory Committee on Immunization Practices (ACIP)
for the Control and Elimination of Mumps. MMWR 2006;55:1–2.

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Key Changes in 2006 Recommendations
for Mumps Vaccine (Cont.)
ROUTINE VACCINATION FOR
HEALTHCARE WORKERS
Persons born during or after 1957 without other
evidence of immunity;
2 doses of a live mumps virus vaccine
Persons born before 1957 without other evidence of
immunity:
consider recommending 1 dose of a live mumps virus
vaccine) Centers for Disease Control and Prevention. Updated recommendations of the
Advisory Committee on Immunization Practices (ACIP)
for the Control and Elimination of Mumps. MMWR 2006;55:1–2.

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Key Changes in 2006 Recommendations
for Mumps Vaccine
FOR OUTBREAK SETTINGS
Children aged 1–4 years and adults at low risk; if
affected by the outbreak, consider a second doseof live
mumps virus vaccine
Healthcare workers born before 1957 without other
evidence of immunity: strongly consider recommending 2
dosesof live mumps virus vaccine
Centers for Disease Control and Prevention. Updated recommendations of the
Advisory Committee on Immunization Practices (ACIP)
for the Control and Elimination of Mumps. MMWR 2006;55:1–2.

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khorfakkan Hospital
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Summary
Mumps is an acute viral infectioninvolves swelling of one or both
parotid glands
Mumps is an RNA virusof the genusRubulavirusin the
Paramyxoviridaefamily
spreadfrom human reservoir by; direct contact.airborne droplets.
fomitescontaminated by saliva and possibly byurine
Transmissiondoes not seem to occurmore than 24 hr beforethe
appearance of the swellingorlater than 3 days afterit has subsided
The incubation periodranges from 14-24 days, with a peakat 17-18
days.
Approximately 30-40%of infections are subclinical
Common complaintsare:earache,discomfortwith eating or drinking
acidic food parotid painis most pronounced duringthe first few days
of swelling

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khorfakkan Hospital
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Summary
the openingof the Stensen ducton the buccal mucosa is edematous
and erythematous.
submandibularand sublingual glandsmay also be involved.
the parotid swellingsubsideswithin 7 to 10 days
The diagnosis of mumps parotitis is usually apparentfrom the clinical
symptomsand physical examination
There is no specific antiviral therapy; treatment is entirely supportive.
Complications include: MENINGOENCEPHALOMYELITIS,
ORCHITIS AND EPIDIDYMITIS, OOPHORITIS , PANCREATITIS,
MYOCARDITIS, ARTHRITIS , THYROIDITIS, DEAFNESS and
OCULAR COMPLICATIONS
The prognosis of mumps in childhood is excellent.
Infection usually confers permanent immunity
Prevention by usage of live attenuated vaccinewhich induces
antibodyin 96%of seronegativerecipients and has 97%protective
efficacy.

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References
Centers for Disease Control and Prevention :Updated
recommendations of the Advisory Committee on Immunization
Practices (ACIP) for the Control and Elimination of Mumps. Morbid
Mortal Wkly Rep MMWR2006;55:366-368.
Centers for Disease Control and Prevention :Update: multistate
outbreak of mumps -United States, January 1-May 2, 2006. Morbid
Mortal Wkly Rep MMWR2006;55:559-563
American Academy of Pediatrics
Mumps. In:PickeringLK,BakerCJ,LongSS,ed.2006 Red Book:
Report of the Committee on Infectious Diseases, 27th ed.. Elk
Grove Village, IL:American Academy of Pediatrics;2006:464.
In:WhartonM,HughesH,ReillyM,ed.Manual for the Surveillance
of Vaccine-Preventable Diseases, 3rd ed.. Atlanta, GA:Centers for
Disease Control and Prevention;2002
Centers for Disease Control and Prevention :Summary of notifiable
diseases, United States, 2003. MMWR2005;52:1