EPIDEMIC PAROTITIS(Mumps)

Prof.Dr. Haluk Çokuğraş

Case-1: 4/12 years old

Fever 3 days; preauricular swelling.Swelling is red and hot. Pus at the orifice of Stensen duct.WBC: 24.000/mm3, left shift, ESR: 50 mm/hr.

Your diagnosis ?

Case-2: 5 years old

Contact of a child with mumps (5 daysago).Preauricular swelling (3x4 cm), and mildfever (2 days)Swelling: Red, hot and tender.WBC: 18.000/mm3; left shift, ESR: 40/hr.

Your diagnosis ?

Case-3: 4 years old

Brother has mumps before 3 weeks.Fever, vomiting and headacheStiffness of the neck, remaining findings are normalWBC: 8.400/mm3, 60% lymphocytes.

CSF: cleary appearence, protein: 60 mg/dl, pandy (+), blood glycose: 110 mg, CSF glycose:75 mg, cells: 120 lymphocytes.

Your diagnosis ?

Amylase level is HIGH

“Mumps is an acute, generalized viral disease in which painful enlargement of the salivary glands, chiefly the parotids, is the usual presenting sign.”

Etiology

Paramyxovirus Only one serotype is known. Cytopathic effect Virus has a predilection for glandular and nervous tissue.

Isolation of the virus

BrainSalivaCSFBloodUrine

Infectivity

Lost of the infectivity as a result of heatingat 55o to 60o C for 20 minutes and after exposure to formalin or to UV light. Infectivity is maintained for years at temperatures of -20o to -70o C.

Epidemiology

Human reservoir onlySpread by direct contact, airborne droplets, fomites contaminated by saliva, and possibly by urine. It is distributed worldwide and affects both sexes equally. Epidemics are slightly more frequent in late winter and spring. 30-40% of infections are subclinical.

Virus has been isolated from saliva as long as 6 days before and up to 9 days after appearance of salivary gland swelling.Transmission: 24 hr before appearence of swelling - 3 days after it has subsided

Lifelong immunity usually follows clinical or subclinical infections, although second infections have been documented.Transplasental antibodies are effective in protecting infants during their first 6-8 mo.

Pathogenesis

Initial multiplication in the cells of the respiratory tract The virus is blood-borne to many tissues.The salivary and other glands are most susceptile

Clinical manifestations:

Incubation period: 14-21 days (mean: 17-18 days)

Prodromal period: Rare in children. Malaise, fever, muscular pain, headache. (24 hr ).

Swelling of the parotid glands

Moderate fever (1-6 days)

Swelling of parotid ( or submandibular-submental ) glands

Bilateral, 25% unilateral.Painful, tender. Never red and hot !More readily appreciated by sight than palpation.Swollen tissues push the ear upward and outward.Duration: 3-7 days.The angle of the mandible is no visible.

Swelling

Bilateral swelling Unilateral swelling

Redness and swelling at theopening of the Stensen (orWharton) duct

Pus Redness and edema

Complications (Manifestations ?)

MeningoencephalitisMyocarditisOrchitis, epididymitisThyroiditisOophoritisMastitisPancreatitisNephritis

DeafnessArthritisOcular complicationsThrombocytopenicpurpuraDiabetes mellitus (?)Mumpsembryopathy

Meningoencephalitis (ME):

Systemic disease 10% of all cases60% of mumps patients have cells in CSFME usually follows the parotitis by 3 to 10 days. The illness is characterized by fever, headache, vomiting, change in sensorium, and meningialirritation signs.CSF: Viral meningitisPatients usually recover completely.

ME may be preinfectious, postinfectious, or even occur in the absence of salivary glandinvolvement

Pancreatitis

Sudden onset of severe epigastric paintenderness, Fever, Chills, Extreme weakness, Prostration, nausea and vomiting. High levels of amylase!The symptoms gradually subside over a periodof 3 to 7 days.Usually full recovering

Orchitis - epididymitisSecond most common manifestation of mumpsin adulthood. It usually follows parotitis, but it may precede it or occur as an isolated manifestationUnilateral involvement 20%-30% in mumpsafter puberty.Bilateral orchitis 2%

OrchitisFever, chills, headache, nausea, vomiting and lower abdominal pain.Testis begins to swell rapidly andbecomes very tender and painful.Bilateral atrophy(rare): Sterility

Deafness

Rare but irreversible complication.Usually unilateral, rarely bilateral.Sudden onset of vertigo, tinnitus, ataxia, and vomiting followed by permanentdeafness.

Mumps embryopathy

The risk is 5% in the first 3mounths of pregnancy.

Cardiac, ocular andneurological symptomsoccur.

Diagnosis

History of exsposure to mumps 2 to 3 weeks beforeonset of illness.Typical clinical signs of parotitis or asepticmeningitis.High levels of amylase.Isolation of causative agentSerological tests: CF, HI, ELISA, virus neutralizationAntibodies are detectable in blood in the 2. week.A fourfold or greater rise in antibody titer (Useful forthe diagnosis of mumps ME without parotitis.)

Differential diagnosis

PAROTITIS:Cervical adenitisSuppurative parotitisRecurrent parotitisCalculusCoxsackie virus infectionParainfluenza 3 virus infectionMixt tumors, hemangiomas, lymphangiomasUveoparotid fever

Differential diagnosis

MENINGOENCEPHALITISCoxsackievirusECHO virusTuberculous meningitisBacterial meningitisOther intracranial pathologies.

Treatment

SymptomaticAcetaminophenAvoidence of sour foodsParenteral fluid therapy (persistentvomiting)

Prophylaxis

Standard immune globulin is ineffective.Mumps immune globulin ?Mumps virus vaccine:

97% protectiveMMR: 1yr old

Case-1: 4/12 years old

Fever 3 days; preauricular swelling.Swelling is red and hot. Pus at the orifice of Stensen duct.WBC: 24.000/mm3, left shift, ESR: 50 mm/hr.

Your diagnosis ?

Case-2: 5 years old

Contact of a child with mumps (5 daysago).Preauricular swelling (3x4 cm), and mildfever (2 days)Swelling: Red, hot and tender.WBC: 18.000/mm3; left shift, ESR: 40/hr.

Your diagnosis ?

Case-3: 4 years old

Brother has mumps before 3 weeks.Fever, vomiting and headacheStiffness of the neck, remaining findings arenormalWBC: 8.400/mm3, %60 lymphocyte.

CSF: cleary appearence, Protein: 60 mg/dl, Pandy (+), Blood glucose: 110 mg, CSF glucose:75 mg, cells: 120 lymphocytes.

Your diagnosis ?

Amylase level is HIGH

Meningoencephalitis

Summary

Fever and bilaterally parotid swellingSwelling isn’t red and hot.Redness and swelling at the orifice of the Stensen duct.40% subclinical infectionMost frequent complication: Meningoencephalitis. Sequeles: DM, deafness, sterility, embryopathy.Rare in the first 6 mo. of life.Prevantion with vaccine.