Rosen & Barkin's 5-Minute Emergency Medicine Consult (462 page)

• Balcer LJ. Clinical practice. Optic neuritis.
  N Eng J Med
  . 2006;354:1273–1280.
  
• Burton JM, O’Connor PW, Hohol M, et al. Oral versus intravenous steroids for treatment of relapses in multiple sclerosis.
  Cochrane Database Syst Rev.
  2012;12:CD006921.
  
• Courtney AM, Treadaway K, Remington G, et al. Multiple sclerosis.
  Med Clin North Am
  . 2009;93:451–476, ix–x.
  
• Filippi M, Rocca MA. MR imaging of multiple sclerosis.
  Radiology.
  2011;259:659–681.
  
• Frohman EM, Racke MK, Raine CS. Multiple sclerosis – the plaque and its pathogenesis.
  N Engl J Med
  . 2006;354:942–955.
  
• Leary SM, Porter B, Thompson AJ. Multiple sclerosis: Diagnosis and the management of acute relapses.
  Postgrad Med J
  . 2005;81:302–308.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Cerebrovascular Accident
  
• Guillain–Barré Syndrome
  
• Lyme Disease
  

CODES

340 Multiple sclerosis

BASICS

Vaccine preventable infectious diseases characterized by swelling of salivary glands, in particular the parotid glands.

• Rubulavirus, single stranded RNA virus, in the Paramyxovirus family
  
• Humans only known reservoir
  

• Mumps vaccine with measles and rubella ± varicella (MMR or MMRV) should be administered to children on or after 12 mo of age. 2nd dose is usually administered at the age of 4–6 yr, before start of school.
  
• Catch-up vaccination should include 2 doses separated by at least 4 wk between vaccinations.
  
• Systemic symptoms and serious complications are less common in children when compared to adults with the infection.
  

Infection during 1st trimester of pregnancy is associated with increased spontaneous abortion. Although mumps virus may cross the placenta, there is no evidence that mumps virus causes congenital malformation.

Adults born before 1957 are considered to have been exposed to mumps and are considered immune. However, during outbreaks, healthcare workers born before 1957 and without lab evidence of immunity to mumps should receive 2 doses of the MMR vaccine.

DIAGNOSIS

• Incubation period from exposure to onset of symptoms (14–18 days):
  
  • Viral transmission is via respiratory droplets, saliva, contact with contaminated fomites
    
  • Replication in nasopharynx and regional lymph nodes
    
  • Viremia to glands as salivary, pancreas, testes, ovaries and also to meninges
    
• Contagious 1–7 days prior to onset of symptoms and 6 days afterward
  
• Often history of none or incomplete immunization
  
• Active illness (1–10 days):
  
  • Nonspecific prodromal symptoms such as low-grade fever, headache, malaise, myalgia, anorexia, otalgia, jaw pain up to 48 hr prior to presentation of parotitis
    
  • Up to 20% of infections are asymptomatic but still contagious
    
  • Up to 50% of cases have nonspecific symptoms of upper respiratory tract infection along with fever, malaise, anorexia, and headache without apparent salivary gland swelling.
    
  • Parotitis
    (30–40% of patients):
    
    • Most common manifestation of mumps. Present in 95% of symptomatic cases of mumps
      
    • Painful and tender unilateral or bilateral (90% of the time) enlargement of parotid gland
      
    • May begin as earache or pain at angle of jaw
      
    • Other salivary gland may be affected.
      
    • Stensen’s duct is often edematous and erythematous and exudes a clear fluid.
      
    • Skin overlying swollen gland is nonerythematous.
      
    • Symptoms decrease after 1 wk and resolve by 10th day.
      
    • Considered contagious until swelling resolves
      
  • Orchitis
    (20–50% of postpubertal males):
    
    • Most common complication in postpubertal males
      
    • May occur alone, before, during, but most commonly, after parotitis
      
    • Unilateral or bilateral (up to 30%)
      
    • Abrupt, painful, tender swelling with nausea, vomiting, and fever
      
    • Pain and swelling resolve in 1 wk
      
    • Testicular atrophy in up to 50% of patients
      
    • Sterility rare
      
  • Oophoritis
    (5% of postpubertal females):
    
    • May mimic appendicitis if right-sided
      
    • Fertility not impaired
      
  • Pancreatitis (2–5%):
    
    • May occur without any other manifestations of mumps
      
    • Fever, nausea, vomiting, and epigastric pain
      
    • May see transient hyperglycemia
      
    • May be complicated by pseudocyst formation and shock
      
  • CNS involvement:
    
    • Aseptic meningitis (10–15% of patients)
      
    • Usually resolves without sequelae in 3–10 days
      
    • Encephalitis (very rare)
      
    • Sensorineuronal deafness (80% unilateral) with permanent hearing impairment
      
    • Cerebellar ataxia
      
    • Transverse myelitis
      
  • Other:
    
    • Myocarditis (rarely with symptomatic involvement)
      
    • Glomerulonephritis
      
    • Polyarthralgia and arthritis
      
    • Thrombocytopenic purpura
      
    • Ocular complaints
      
    • Thyroiditis
      
    • Mastitis
      

Diagnosis is based on clinical findings of parotitis and associated signs, symptoms, and complications.

• Lab tests as needed
  
• Cerebrospinal fluid (CSF) for symptomatic CNS involvement
  
• Hyperamylasemia usually due to parotitis and supports diagnosis
  
• Mumps RNA detection using PCR assays, mumps viral cultures, or enzyme immunoassays for mumps IgM antibody or significant rise in IgG titers between acute and convalescent specimens:
  
  • Provides definitive diagnosis
    
  • Viral culture may be from blood, throat swab, salivary gland secretions, CSF, or urine. PCR provides rapid confirmation of mumps in CSF
    
  • Not indicated unless need to confirm diagnosis in absence of parotitis
    

• Bacterial parotitis:
  
  • Commonly
    Staphylococcus aureus
    
  • Erythematous and tender parotid gland
    
  • Usually in elderly or immunocompromised
    
• Calculus parotid:
  
  • Stone may be palpable or may be seen on sialogram (CT)
    
• Cervical adenitis
  
• Tumors:
  
  • Older patients
    
  • History of indolent course
    
• Testicular torsion
  
• Bacterial epididymo-orchitis
  
• Other viral cause of parotitis; influenza A, parainfluenza, cytomegalovirus, coxsackieviruses, HIV
  

TREATMENT

Nonimmunized pre-hospital care personnel exposed to mumps should be advised of potential risks.

IV fluids for vomiting/dehydration

• Prevention with mumps vaccination is cornerstone of therapy
  
• Supportive therapy:
  
  • Antipyretics
    
  • Analgesia:
    
    • Acetaminophen, NSAIDs, narcotics (for severe pain)
      
  • IV fluids and antiemetics for vomiting and dehydration
    
  • Ice pack
    
  • Scrotal support and bed rest for orchitis
    
• Isolation, droplet precaution, of infected patients
  

FOLLOW-UP