Mumps

What are mumps?

Mumps (or “the mumps”) is the more common name for parotitis. It is a viral infection that causes your parotid glands to swell. Your parotid glands are located between your ear and jaw.

These glands make the saliva (spit) that helps you chew and swallow food. In serious cases, mumps can affect other organs. Mumps is most common in children 2 to 12 years of age who haven’t received the mumps vaccine, but you can catch it at any age.

7 Interesting Facts of Mumps

1. Mumps is an acute, self-limited viral illness caused by paramyxovirus
2. Typical clinical presentation includes prodromal symptoms (eg, fever, malaise, headache, anorexia, myalgia) followed within a few days by parotid swelling and tenderness 
3. Diagnosis is made on the basis of history of exposure, suggestive physical examination results, and laboratory test results 
4. Presence of serum mumps IgM designates the infection as probable according to CDC criteria. A positive mumps virus culture or detection of virus by real-time reverse transcriptase polymerase chain reaction test confirms the diagnosis 
5. Treatment of mumps is palliative and supportive with rest, hydration, antipyretics, and analgesics 
6. Mumps vaccine should be administered to children as a 2-dose regimen beginning at age 12 months and to all high-risk adults 
7. Most common complication of mumps is orchitis; other rare complications include meningitis, oophoritis, mastitis, pancreatitis, and deafness 

What are the symptoms of mumps?

The most noticeable symptom of mumps is facial swelling, or “chipmunk cheeks,” caused by the swollen salivary glands. This swelling can be very painful, and is sometimes the only symptom. The swelling usually occurs on the second day of illness and lasts from 5 to 7 days. Many people also experience:

• Face pain
• Fever as high as 103°F to 104°F starting after the first few days and lasting for 2 to 3 days
• Chills
• Lack of appetite
• Headache
• Sore throat
• Swelling of the temples or jaw

When should I see a doctor?

There is no medicine to treat mumps. It usually goes away on its own within 2 weeks. Because it is a viral infection, antibiotics cannot treat mumps.

Rarely, mumps can spread to other areas of the body, which may lead to other serious conditions. It can cause swelling of the testicles, the ovaries, the pancreas and the brain. It can also lead to hearing loss and meningitis (infection of membranes that cover the brain and spinal cord). Mumps can also cause miscarriage in pregnant women. Call your doctor if you notice:

• Severe headache
• Stiff neck
• Eye redness
• Drowsiness
• Abdominal pain
• Vomiting
• Testicle pain or lump

Women who are pregnant and may have been exposed to mumps should call the doctor, even if they don’t show any symptoms.

If seizures occur, seek emergency medical care.

What causes mumps?

Mumps is caused by a virus that is spread by infected saliva. This means the virus can spread very much like the common cold. For example, if an infected person sneezes near you or you touch something that an infected person has touched, and you have not been vaccinated, you may get the mumps. Normally, you won’t get sick until 12 to 24 days after being exposed to the virus. These 12 to 24 days are called the incubation period.

How are mumps treated?

If you or your child has mumps, the only thing to do is let the infection run its course. In the meantime, you can take some steps to relieve discomfort:

• Place ice or heat packs on swollen cheeks.
• Take acetaminophen (brand name: Tylenol) for pain or ibuprofen (brand names: Advil, Motrin) for pain and swelling. Never give aspirin to children or teenagers 18 years of age or younger because of the risk of Reye’s syndrome. Reye’s syndrome is a serious illness that can lead to death.
• Drink plenty of fluids to stay hydrated.
• Eat soft foods that don’t require much chewing.
• Avoid acidic foods or foods that make your mouth water, such as citrus fruits.
• Gargle with warm salt water several times a day.
• Try popsicles to soothe your throat.
• If the testicles are swollen, support the scrotum with an athletic supporter. Ice packs may help reduce pain. Long-term problems, such as sterility (not being able to have children), are very rare.
• Try to avoid public places and close contact for at least 5 days after symptoms appear. This is the period of time during which you are the most contagious.

Usually, people who have the mumps once become immune to it for life and can’t get it again.

Can mumps be prevented?

Yes. The measles, mumps and rubella (MMR) vaccine  prevents the mumps in 80% to 90% of people. Two doses are more effective than one. Thanks to this vaccine, very few people get the mumps in the United States anymore. However, outbreaks can still occur in locations where vaccination rates are low.

The MMR vaccine is usually given to infants 12 to 15 months of age. Children often are given the vaccine between ages 4 to 6 or between ages 11 to 12 if they haven’t yet received it. However, it is never too late to be vaccinated. If you work in a public setting or in the health care field, you should get vaccinated if you haven’t already. Talk to your doctor if you think you may need to be vaccinated.

Pitfalls

• In both unvaccinated and vaccinated persons, false-positive laboratory results can occur because assays may be affected by other causes of parotitis. False-negative results are common in vaccinated persons 
  • With previous contact with mumps virus either through vaccination (particularly with 2 doses) or natural infection, IgG test results may be positive at the initial blood draw, mumps IgM test results may be negative, and viral detection by culture or real-time reverse transcriptase polymerase chain reaction test may have low yield if the buccal swab is collected more than 3 days after onset of parotitis 
  • Negative laboratory results among vaccinated persons do not necessarily rule out the diagnosis of mumps, particularly if there is an outbreak of parotitis 
• It may be difficult to differentiate between mumps meningitis and bacterial meningitis based on cerebrospinal fluid examination because both have similar characteristics (eg, decreased glucose level with a moderate to marked pleocytosis) 

Mumps is an acute, self-limited viral illness caused by paramyxovirus 

Most common presentation is nonsuppurative swelling and tenderness of the parotid or other salivary glands 

History

• May report a history of exposure to mumps 
• Symptoms typically appear 16 to 18 days after exposure; usually mild and self-limited 
  • Nonspecific prodromal symptoms are usually followed within a few days with parotid gland swelling and tenderness; symptoms usually resolve within 10 days 
    • Prodromal symptoms
      • Low-grade fever (may last for 3-4 days) 
      • Malaise 
      • Headache 
      • Anorexia 
      • Myalgia 
    • Glandular swelling
      • Swelling of parotid and other salivary glands under the ears on 1 or both sides 
    • Facial pain
      • Most painful during time of rapid parotid enlargement (within 2 to 3 days) 
      • Eating citrus fruits or juices usually exacerbates pain 
    • Associated earache 
    • Dysphagia 
    • Difficulty chewing 
    • Dysphonia 
  • If orchitis occurs (most common complication):
    • Testicular pain
  • If central nervous system involvement occurs (uncommon):
    • Headache
    • Stiff neck
    • Nausea and vomiting
    • Photophobia
    • Hearing loss
    • Seizure
  • Rarely, clinical manifestations of oophoritis, mastitis, or pancreatitis may occur
• About one-third of patients are asymptomatic 

Physical examination

• Fever 
  • Usually low-grade but can be up to 40 °C 
• Enlarged, firm, and tender parotid gland (60% of cases) 
  • Single parotid involvement in 25% of cases; when both are involved the second parotid usually enlarges 1 to 2 days after the first 
  • Reaches maximal size in 2 to 3 days 
  • Lifts the earlobe upward and outward 
  • Obscures angle of mandible 
  • Swollen and edematous orifice of the parotid duct 
• Enlarged and tender submandibular and/or sublingual salivary gland (10% of cases) 
  • Usually in conjunction with parotitis 
• Reduced opening of the jaws due to trismus 
• Meningismus/nuchal rigidity if complicated by aseptic meningitis
• Warmth, swelling, and tenderness of testicle (20%-30% of postpubertal men historically; in recent outbreaks up to 10% of cases) with orchitis 
  • Enlargement of the testis from 3 to 4 times its normal size is possible 
  • Associated with erythema of the scrotum
  • Bilateral in 1 out of 6 cases 

Causes

• Caused by paramyxovirus, which is transmitted via direct contact with respiratory droplets or through fomites 
• Most transmission occurs several days before and after parotitis onset; transmission can also occur from asymptomatic persons 

Risk factors and/or associations

Age

• In the prevaccine period, 90% of cases occurred in children younger than 14 years; since then about 49% of cases occur in persons older than 15 years 
• Rarely occurs in infants younger than 12 months because of passive immunity acquired by the placental transfer of maternal antibody 

Diagnostic Procedures

Primary diagnostic tools

• Diagnosis of mumps is made based on history, physical examination, and corroborative laboratory test results 
• Clinical diagnosis of mumps may be unreliable; seek laboratory verification using IgM and/or IgG serology, culture, or polymerase chain reaction testing 
• CDC classifies mumps infection as suspect, probable, or confirmed based on the following criteria: 
  • Suspect 
    • Parotitis, acute salivary gland swelling, orchitis, or oophoritis unexplained by another more likely diagnosis, or 
    • A positive laboratory test result with no clinical symptoms of mumps (with or without epidemiologic linkage to a confirmed or probable case) 
  • Probable 
    • Acute parotitis or other salivary gland swelling lasting at least 2 days, orchitis, or oophoritis unexplained by another more likely diagnosis, in: 
      • A person with a positive test result for serum mumps IgM antibody, or 
      • A person with epidemiologic linkage to another probable or confirmed case or linkage to a group/community defined by public health authorities during an outbreak of mumps 
    • Confirmed 
      • A positive laboratory test result for mumps virus with real-time reverse transcriptase polymerase chain reaction test or culture in a patient with an acute illness characterized by any of the following: 
        • Acute parotitis or other salivary gland swelling lasting at least 2 days 
        • Aseptic meningitis 
        • Encephalitis 
        • Hearing loss 
        • Orchitis 
        • Oophoritis 
        • Mastitis 
        • Pancreatitis 
• Lumbar puncture for cerebrospinal fluid testing is indicated if there is suspected central nervous system infection 

Laboratory

• Virus detection by real-time reverse transcriptase polymerase chain reaction test or culture 
  • Fluid samples can be collected from the parotid duct, other affected salivary gland ducts, the throat, urine, and cerebrospinal fluid 
    • Parotid duct swabs provide the best sample, especially when the salivary gland area is massaged for about 30 seconds before swabbing the buccal/parotid duct 
    • Urine samples may not contain sufficient virus copies or virus-infected cells for culture or detection by molecular methods 
    • Obtain clinical specimens ideally within 3 days and no more than 8 days after onset of parotitis 
    • Confirm isolation of paramyxovirus by culture using immunofluorescence with a mumps-specific monoclonal antibody or by molecular techniques (eg, real-time reverse transcriptase polymerase chain reaction test) 
• Serology 
  • Acute mumps infection can be detected by the presence of serum mumps IgM, a significant rise in IgG antibody titer in acute and convalescent-phase serum specimens, or IgG seroconversion 
  • Techniques for mumps IgM antibody include enzyme immunoassay (preferred) and immunofluorescence assay; for mumps IgG antibody, they include enzyme immunoassay, immunofluorescence assay, and plaque reduction neutralization 
    • Diagnosis of mumps with IgM serology 
      • Obtain an initial serum specimen to test for mumps IgM antibodies. If the acute-phase specimen test result is positive for IgM, a second specimen is not necessary. A second negative IgM test result does not rule out mumps unless the convalescent phase IgG test result is also negative 
      • Enzyme immunoassay for testing IgM has a high specificity 
      • Immunofluorescence assay testing for IgM can be problematic because nonspecific staining may cause false-positive results if the serum is not treated with an agent to remove human IgG antibody 
    • Diagnosis of mumps with IgG serology 
      • Seroconversion from negative to positive on a convalescent-phase specimen (2-3 weeks after onset) by enzyme immunoassay or a 4-fold rise in the titer of antibody against mumps as measured in plaque-reduction neutralization assays or similar quantitative assays 
        • Conduct tests for IgG antibody on both acute- and convalescent-phase specimens at the same time. Use the same type of test on both specimens. Enzyme immunoassay values are not titers, and increases in enzyme immunoassay values do not directly correspond to titer rises 
        • In vaccinated persons, the IgG may already be very high in the acute-phase blood sample; this often prevents detection of a 4-fold rise in IgG titer in the convalescent serum specimen
    • Testing mumps immunity with IgG 
      • Presence of mumps-specific IgG, as detected using a serologic assay (enzyme immunoassay or immunofluorescence assay), is considered evidence of mumps immunity but does not necessarily predict the presence of neutralizing antibodies or protection from mumps disease 
  • False-positive and false-negative laboratory test results 
    • Do not rule out mumps based on negative laboratory test results in a person with previous contact with mumps virus either through vaccination (particularly with 2 doses) or natural infection 
      • IgG test results may be positive at the initial blood draw
      • Mumps IgM test results may be negative
      • Viral detection by culture or real-time reverse transcriptase polymerase chain reaction test may have low yield if the buccal swab is collected more than 3 days after onset of parotitis
    • False-positive results may occur on IgM immunofluorescence assays owing to interference from high levels of mumps-specific IgG 

Procedures

Lumbar puncture

General explanation

• Insertion of a hollow-bore needle between the vertebral bodies into the subarachnoid space to obtain a specimen of cerebrospinal fluid

Indication

• Suspected nervous system involvement (eg, meningitis, encephalitis)

Contraindications

• Uncontrolled coagulopathy
• Skin infection at site of needle insertion
• Patient at risk of brain herniation 
  • Best predictors of precipitating herniation (even with normal CT result) include:
    • Deteriorating level of consciousness (particularly to a Glasgow Coma Scale score of 11 or less)
    • Brainstem signs (eg, pupillary changes, abnormal posturing, irregular respirations)
    • Very recent seizure

Interpretation of results

• Cerebrospinal fluid pleocytosis occurs in over one-half of mumps cases, often without other signs or symptoms of meningitis 
  • Cerebrospinal fluid contains 10 to 2000 WBCs/mm³, mainly lymphocytes, but 20% to 25% of patients have a polymorphonuclear leukocyte predominance 
• Protein levels are within to slightly above the reference range; 90% to 95% of patients have a protein content less than 70 mg/dL
• Glucose concentration of less than 40 mg/dL is present in 6% to 30% of patients 
• Real-time reverse transcriptase polymerase chain reaction test or culture results will be positive

Differential Diagnosis

Most common

• Acute nonparamyxovirus viral parotitis
• Conditions that can cause unilateral parotid swelling
• Suppurative parotitis
• Noninfectious conditions that can cause bilateral parotid swelling
• Parotid enlargement caused by drugs – Can be differentiated from mumps clinically by absence of symptoms (other than parotid enlargement) and history of use of certain medications such as phenylbutazone, thiouracil, iodides, and phenothiazines

Treatment Goals

• Provide comfort measures to relieve symptoms 
• Prevent complications
• Prevent spread of infection to others

Admission criteria

• Patients with encephalitis or meningitis may require admission for supportive care

Recommendations for specialist referral

• Referral to an infectious disease specialist may be necessary for appropriate diagnostic evaluation and treatment
• Mumps is a reportable disease; report probable and confirmed mumps cases to the state health department 

Treatment Options

Isolate patients with mumps at home for 5 days after onset of symptoms 

Treatment of mumps includes hydration, rest, antipyretics, and analgesics 

Drug therapy

• Antipyretics and analgesics to relieve fever and pain

Nondrug and supportive care

• Hydration
• Rest

Complications

• Complication rate increases with age up to 50 years 
• Increased complication rate in men (1.5 times higher) 
• Orchitis
  • Orchitis occurs in approximately 20% to 30% of unvaccinated and 6% to 7% of vaccinated postpubertal male mumps patients 
  • Orchitis is unilateral in up to 83% of cases caused by mumps 
  • Characterized by fever (39 °C to 41 °C), chills, headache, vomiting, and testicular pain. Increased warmth, swelling, and tenderness of the involved testicle, with scrotal erythema, are usually found on genital examination 
  • Epididymitis is present in 85% of cases of orchitis; usually precedes orchitis and rarely occurs without it 
  • Sterility is rare even when bilateral 
• Meningitis (Related: Viral meningitis)
  • Meningitis occurs in 1% to 10% of patients with mumps parotitis; however, only 40% to 50% of patients with mumps meningitis, confirmed by viral isolation or serology, have parotitis 
  • Spreads to the central nervous system by either hematogenous or neuronal routes 
  • Characterized by fever, headache, nuchal rigidity, nausea, and vomiting 
  • Presents about 4 days after the onset of parotitis but may be as early as 1 week before or as late as 2 weeks after 
  • Occurs 3 times more often in men than in women 
  • It may be difficult to differentiate between mumps meningitis and bacterial meningitis based on the cerebrospinal fluid examination because both have similar characteristics (eg, decreased glucose level with a moderate to marked pleocytosis); polymerase chain reaction test or culture results are diagnostic 
  • Treat patients with meningitis with antibiotics until bacterial culture results are negative or until a definitive diagnosis of mumps is made
• Oophoritis (1% or less of adolescent girls and women)
  • Characterized by fever, nausea, vomiting, and lower abdominal pain 
  • Rare occurrences of premature menopause and fertility problems 
• Mastitis (1% or less of adolescent girls and women)
  • Characterized by fever and breast tenderness, increased warmth, swelling, and erythema
• Hearing loss (less than 1%)
  • When sensorineural hearing loss occurs, it is profound and frequently permanent 
• Pancreatitis ( ) (Related: Acute pancreatitis)less than 1%
  • Characterized by severe epigastric pain and tenderness, fever, nausea, and vomiting 
• Encephalitis (less than 0.2%) (Related: Encephalitis in adults)
  • Spreads to the central nervous system by either hematogenous or neuronal routes 
  • Is associated with more serious central nervous system sequelae including persistent headaches, deafness, and optic atrophy 
• Thyroiditis 
  • Rare occurrence 
  • Associated with parotitis, but may occur up to months after the development of parotitis 
  • Characterized by thyroid gland enlargement, hoarseness, and dysphagia 
• Pharyngolaryngeal edema with dyspnea 
  • Rare occurrence 
  • Usually associated with submandibular gland swelling, probably as a result of lymphatic flow disturbance and local inflammation 
  • Can cause airway stenosis 
  • Generally responds to steroids, but it may require tracheotomy 

Prognosis

• Mumps is usually benign and self-limiting, with about one-third of affected persons being asymptomatic 
• Mumps orchitis occurs in up to 10% of males, but it rarely results in sterility 
• Mumps meningitis is also mainly benign, without long-term sequelae 
• Mumps encephalitis has about 1.5% mortality 

Prevention

• Prophylaxis
  • Vaccine
    • Current vaccines include measles, mumps, and rubella (MMR) and measles, mumps, rubella, and varicella (MMRV) 
      • Dosing regimen in children
        • Administer a 2-dose series of measles, mumps, and rubella vaccine at ages 12 through 15 months and 4 through 6 years. The second dose may be administered before age 4 years, as long as at least 4 weeks have elapsed since the first dose 
        • Administer 1 dose of measles, mumps, and rubella vaccine to infants aged 6 through 11 months before departure from the United States for international travel. These children should be revaccinated with 2 doses of measles, mumps, and rubella vaccine, the first at age 12 through 15 months (12 months if the child remains in an area where disease risk is high) and the second dose at least 4 weeks later 
        • Administer 2 doses of measles, mumps, and rubella vaccine to children aged 12 months and older before departure from the United States for international travel. The first dose should be administered on or after age 12 months and the second dose at least 4 weeks later 
      • Dosing regimen in adults
        • 2 doses of measles, mumps, and rubella vaccine are also recommended for adults at high risk, including international travelers, college and other post–high school students, and health care personnel born in or after 1957. All other adults born in or after 1957 without other evidence of mumps immunity should be vaccinated with one dose of measles, mumps, and rubella vaccine 
      • 2 doses of the vaccine are about 88% effective in preventing mumps infection and 1 dose is about 78% effective 
      • Measles, mumps, and rubella vaccine is not recommended for immunocompromised patients, but may be given to asymptomatic HIV-positive children 
      • Measles, mumps, and rubella vaccine is contraindicated in pregnant women 
    • Mumps has been reported in vaccinated individuals; 63% of mumps patients with known vaccination status in a 2006 outbreak had received 2 doses of vaccine 
• Postexposure prophylaxis 
  • Mumps vaccine may not provide adequate protection in preventing mumps infection from a recent exposure, but it is recommended to prevent future illness 
  • Mumps immunoglobulin is not effective and is not available in the United States 
• Persons at increased risk for mumps during an outbreak
  • Owing to an increase in the number of mumps outbreaks and outbreak-associated cases in the United States since late 2015, the Advisory Committee on Immunization Practices determined that a third dose of measles, mumps, and rubella vaccine is safe and effective at preventing mumps 
  • Persons previously vaccinated with 2 doses of a mumps virus–containing vaccine (measles, mumps, and rubella or measles, mumps, rubella, and varicella) who are identified by public health authorities as being part of a group or population at increased risk for acquiring mumps because of an outbreak should receive a third dose of a mumps virus–containing vaccine to improve protection against mumps and related complications 
• Controlling outbreaks in schools and colleges 
  • Students who have not been vaccinated and have no immunity to the mumps virus should not attend school until they have received the vaccine or until the 26th day after the onset of parotitis in the last person with mumps in the affected school 
  • Persons previously vaccinated with 1 or 2 doses of a mumps virus–containing vaccine who are identified as having increased risk for mumps because of the outbreak should receive a dose of a mumps virus–containing vaccine (second dose for persons previously vaccinated with 1 dose or a third dose for persons previously vaccinated with 2 doses) to improve protection against mumps and its complications 
• Prevention and control strategies in health care settings 
  • Apply prevention and control strategies in all health care settings, including outpatient and long-term care facilities 
    • Assessment of presumptive evidence of immunity of health care personnel (documented administration of 2 doses of live mumps virus vaccine, laboratory evidence of immunity, laboratory confirmation of disease, or birth before 1957) 
    • Vaccination of those without evidence of immunity 
    • Exclusion of health care personnel with active mumps illness, as well as health care personnel who do not have presumptive evidence of immunity who are exposed to persons with mumps 
    • Isolation of patients in whom mumps is suspected 
    • Implementation of droplet precautions, in addition to standard precautions

Questions to Ask Your Doctor

• What can I do to make my child more comfortable?
• How long will I be contagious?
• How long should I keep my child home from school?
• Am I at risk for any complications?
• Will mumps make me sterile?
• How soon should I have my child vaccinated against mumps?
• Should I isolate my child from the rest of the family until he/she is no longer contagious?
• If I feel worse, when should I call my doctor?
• If I haven’t been vaccinated, should I be?

Sources

Clemmons N: Mumps. In: CDC: Manual for the Surveillance of Vaccine-Preventable Diseases. Web ed. CDC website. Reviewed January 31, 2018. Accessed February 18, 2020. http://www.cdc.gov/vaccines/pubs/surv-manual/chpt09-mumps.html Reference