Monday, February 25, 2013

All You Need To Know About Mumps (Infectious Parotitis)

Mumps (parotid infection) is an acute viral disease, that is caused by a virus from Pramyxovirus family, is transmitted by droplet mechanism, is characterized by the predominant damage of salivary glands, rarer - other glandular organs (pancreas, testicles, ovaries, pectoral glands and other), and also nervous system.
Etiology: an RNA virus, myxovirus parotitis, pathogenic only in humans.

A source is a patient with clinical, effaced, subclinical forms of infection, contagiousness is up to 9 days from the beginning of disease;
the mechanism of transmission is droplet, the virus is transmitted primarily through saliva during speaking, breathing (air-droplet way), hand-to-hand (contact way);
the morbidity index does not exceed 50%, more frequent children 3-6 years are ill;
Immunity is persistent.

Acquired through the mucous membrane of oral cavity, pharynx, respiratory tract, the virus proliferates locally and in regional lymph nodes;
Then occurs a viremia;
Dissemination of the virus to salivary glands,
Reproduction in them
Secretion of the virus by saliva
Secondary viremia
Damage of other organs: pancreas, testes, ovaries, thyroid, breasts and meninges.
Immune response, elimination of the virus.

Organs that are could be damaged by parotid infection

Typical forms 
glandular (parotitis, submaxillitis, sublinguitis, pancreatitis, orchitis, oophoritis,  mastitis, bartolonitis, prostatitis, tyroiditis);
nervous (serous meningitis, meningoencephalitis);
combined (parotitis pancreatitis + serous meningitis).
Atypical forms
subclinical (without clinical signs).
Severity:    -
mild degree;
moderate degree;
severe degree.
further asthenic, hypertensive syndrome (in case of encephalitis);
Severity indexes:
degree of glands damage (swelling, tenderness, edema);
the CNS damage (meningeal and meningoencephalitis signs severity);

degree of toxic syndrome (body temperature, violation of the common state).

Clinical presentation

Incubation period range 11-21 days.
Prodromal symptoms are: general malaise, anorexia, and myalgia with a low-grade fewer. They are followed by parotitis; other manifestations may include pancreatitis, oophoritis, orchitis, mastitis, myocarditis, meningoencephalitis and cranial nerve involvement. These symptoms can occur singly, sequentially or concurrently.
Parotitis presents as an earache, parotid edema begins with erythema (or usually colorless) and tenderness above the angle of the mandible (during chewing, speaking) within 1-2 days. Edema increases over several days, may cause an upturning of the earlobe (photo). An examination of the buccal mucosa often reveals erytematous and edematous orifices of Wharton`s and Stensens ducts (Positive Moorson sign). Fever may increase to 40 oC. Another parotid gland usually inflamed in 1-2 days.
Other signs of mumps tend to occur 1 week or more after the onset of parotid edema.

Bylateral parotitis

 Upturing of the earlobe

Moorson sign

Acute beginning from fever (temperature 38 - 39°С), toxic syndrome.
Pain in the area of the damaged gland.
Slight swelling in submandibular area.
Hyperemia and infiltration in the place of external duct of salivary gland.
Often comes with the damage of parotid glands.

Orchitis: symptoms include testicular edema and tenderness, nausea, vomiting and fever. In 25 % - is bilateral. Mild atrophy of one testis may develop in many cases.
Repeated rising of temperature on 7 - 14 day of illness, toxic syndrome.
Previous damage of salivary glands.
Pain in a groin increases at walking with an irradiation in a testicle.
A testicle is enlarged in sizes; thickened, very painful, skin of scrotum above him is red, shining.
In future is violation of testicles function, atrophy in 1/3

Oophoritis is found primarily in post pubertal patients.
Mastitis has been described in 1/3 post pubertal females.
Meningoencephalitis is one of most significant manifestations of mumps. Meningitis symptoms are: fever, headache, nausea, and vomiting, nuchal rigidity. Encephalitis may present with convulsions, focal neurologic signs, movement disorders, or marked changes in sensory. Muscular weakness, loss or reflexes indicate myelin involvement.
Develops secondary on 7 - 10 day of illness, it is combined with the of salivary glands defeat.
Toxic syndrome, repeated increase of temperature.
Total cerebral syndrome: headache, nausea, repeated vomits, languor.
Meningeal syndrome.
In the cerebro-spinal fluid lymphocytic (95 - 98 %) pleocytosis (hundred, thousand cells in 1 mm3), increased protein (0.99 - 1.98g/l), normal level of sugar, chlorides, increased pressure.
Favorable course of the disease.
Pancreatitis manifests with upper abdominal pain and tenderness in the epigastrium.
Develops secondary on 5 - 7 day of illness, it is combined with the of salivary glands defeat.
Dyspepsia (nauseavomitsdiarrhea).
Amylase, lipase, trypsin in the blood are increased
Amylase in the urine is increased
In coprogram – signs op enzymopathy.
Myocarditis occurs primarily in adults, presenting with ECG changes.
Joint, thyroid, renal and prostate involvement may also occur.

Laboratory tests are usually not helpful. Serum amylase increases. Most laboratories are also no equipped to differentiate between parotid and pancreatic amylase. A lumbar puncture is necessary in a patient with “severe” neurological findings (shows serous meningitis).
In the blood – leucopenia (may be leucocytosis in the beginning)relative lymphocytosisshift to the left, rare – monocytosis, or elevated ESR.
SerologyNRCBRDHARwith paired sera.
Immune-enzyme method (ELISA) – presence of specific antibodies (Ig M) to the mumps virus.

Diagnosis example:
Mumps, typical isolated glandular form (bilateral parotitis, left side submaxillitis), moderate severity, uncomplicated.
Mumps, typical poliglandular form (bilateral parotitis, pancreatitis, bilateral orchitis) severe degree, complicated by the bilateral bronchopneumonia.
Mumps, typical combined form (bilateral submaxillitis, sublinguitis, meningitis), severe degree, uncomplicated.

Differential diagnose:
The viral agents, parainfluenza types 1 and 3, Coxsackie’s – virus A, Epstein-Barr virus (EBV), cytomegalovirus (CMV), and echovirus, may all cause parotitis.
Purulent parotitis most often caused by staphylococcus, pneumococcus, or gram-negative bacilli.

Noninfectious causes of parotid enlargement include obstruction, tumors, congenital or acquired cysts and drugs such as iodides and phenothiazines.
Cervical lymphadenitis, toxic form of diphtheria must be excluded.

Submandibular and cervical lymphadenitis

Differential diagnose of the Mumps

Diphtheria of the pharynx (toxic)
Infectious mononucleosis
Purulent parotitis
Main syndrome
Salivary glands,other glands damagetoxic syndrome
Membranous tonsillitistoxic syndrome
toxic syndrome
Isolated parotitis,
toxic syndrome
Deformation of the neck is due to:
Salivary glands inflammation
Subcutaneous tissue edema
Cervical lymph nodes enlargement
Purulent unilateral parotitis
Skin upon the edema
Normal color
Normal color
Normal color
Local temperature
Mild or moderate
Tissues thickness
Changes in the oral cavity, pharynx
Edema, redness ofWharton`s and Stensens ducts orifices
Throat hyperemia, Membranous tonsillitis
Catarrhal, follicular,
or lacunar tonsillitis
Edema, redness ofsalivary ducts external orifices, purulent exudates from it after gland palpation
Damage of other organs

Hepato-, splenomegaly
Complete blood test
leucopenia,lymphocytosisshift to the left
leucocytosis,neutrophyllosis, shift to the left
leucocytosisor leucopenia, lymphocytosisatypical mononuclears
leucocytosis,neutrophyllosis, shift to the left

Treatment is symptomatic. In mild, moderate cases of isolate salivary glands damage home treatment is indicated.

Basic therapy in case of
Isolate salivary glands damage (parotitis, submaxillitis, and sublinguitis):
Bed regimen up to 7 days.
Mechanically sparing diet (liquid, semi liquid, soft food; exclude uncooked vegetables and fruits, juices, fatty and spicy food)
Care for oral cavity (gurgling with 2 % NaHCO3, 5% boric acid, and other antiseptic solutions).
Dry heat on the staggered glands.

In case of Pancreatitis additionally:
1 - 2 days hunger, diet №5 for 10 - 12 days.
Detoxication therapy (orally, IV: crioplasm, albumen, 5% glucose, physiologic sodium chloride solution).
Protease inhibitors (contrical 10-20 IU/kg/day)
Spasmolytics for the pain syndrome decrease (nospani, papaverini).
Enzymic preparations (pancreatin, creon, pangrol, digestin).

In case of Orhitis additionally:
Bed regimen up to 10 days, suspensorium.
Glucocorticoids 2-3 mg/kg (in equivalent to prednisolone) in 3 - 4 receptions 3 - 4 days, gradual diminishment of dose, course 7 - 10 days.
Analgesics (analgin, ibuprophen).

In case of Meningitis
Base therapy:
Bed regimen till body temperature normalization, improvement of general condition, and CSF parametres, not less than 7-10 days, besides – semibed regimen during 5-7 days;
A diet (before stable vital functions is due to adequate parenteral infusion therapy),
Brest feeding or bottle feeding by adopted formulas for infants, in the first day 1/2-1/3 of average volume with a next increase to the complete volume during 2-3rd days, in case of impaired swallowing – nasogastric tube feeding.
A milk vegetable diet (№5) is appointed for preschoolers or school children, 5-6 times per day with the next passing to the diet №2 whether №15 (depending the age) in the recovery period;
Oral fluids intake corresponds to age norms (with including the IV fluids);
Pathogenetic therapy:
In case of brain edema – dehydration by 25 % MgSO4 IM, lasix 1-3 mg/kg IV or IM, acethazolamid orally;
Detoxication in moderate case – orally (oral fluids intake corresponds to age norms with including the IV fluids);
Detoxication in severe cases – IV not more than 1/2 of physiologic age norms during the 1st day, total fluids intake (IV and PO) not more than 2/3 of physiologic age norms in case of normal urination and absense of dehydration. From the 2nd week correct fluids intake (daily amount of urine not less than 2/3 of all fluids intake);
In case of seizures – Anticonvulsant therapy: benzodiasepins (seduxenum, sibasonum) 0.3-0.5 mg/kg IV, if they are ineffective – 1 % hexenalum or thiopenthalum sodii in 3-5 mg/kg IV. Dehydration therapy: lasix 2-3 mg/kg IM or IV.
Etiologic therapy is indicated in severe cases:
• Recombined interpheron for 7-10 days.
• Endogen interpheron inductors.
• Antiviral medicine (innosini pranobex – 50 mg/kg).

Isolation of contacts (aged to 10 years, not vaccinated, and were not ill before), from 11 till 22 day after the contact: examination, temperature measuring.
Ventilation, moist cleaning up.
Vaccination by a living mumps vaccine (or combined MMR vaccine together with vaccination against measles, rubella) in 12-15 months. Revaccination - in 6 years, if was not done - in 11 years; in 15 years - monovaccine (boys).
Key words and phrases: mumps infectious parotitis, earlobe, orifices of  Wharton’s and Stensen’s ducts, parotid edema, orchitis, oophoritis, mastitis,  meningoencephalitis, meningitis, encephalitis, pancreatitis, myocarditis, lumbar puncture.

1.     Current therapy in pediatric infectious diseases – 2 edited by John D. Nelson, M. D. – B.C. Decker  inc. Toronto, Philadelphia, 1988, - P. 134-138, 285.
2.     Ambulatory pediatric care (edited by Robert A. Derchewitz; - 2 nd ed. – Lippincot – Raven, 1992. – P. 570-574; 255.          
3.     Principles and Practice of Pediatric Infectious Diseases. / Edited by Saran S. Long, Larry K. Pickering, Charles G. Prober, PhiladelphiaPa: Churchill Livingstone; 1997. – 1921 p.

1.     Textbook of Pediatric Nursing.  Dorothy R. Marlow; R. N., Ed. D. –London, 1989.-661p.
2.     Pediatrics ( 2nd edition, editor – Paul H.Dworkin, M.D.) – 1992. – 550 pp.

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