Interesting Case Rounds: “Sweet Cheeks”

James HuffmanPGY-2 Emergency MedicineOctober 11, 2007Thanks to Dr. Arun Abbi

Presentation

24 y.o. male paramedic presents to PLC ED ~2300h Triage: “left facial swelling and pain. started this evening” 38.4°C, 82, 18, 132/78, 96% ra, BG=4.8 HPI:

Feeling lethargic and generally sore for the past 36 hours. Headache and anorexia developed through the day. Felt dull, left-sided jaw angle pain ~1800h, napped and when he

woke up his jaw was significantly more sore and his partner noticed large left-sided facial swelling. To ED.

No history of similar episodes. No known infectious contacts. No travel

Presentation

PMHx: healthy – remote ear infections No meds, NKDA OE:

Unilateral left-sided facial swelling. Exquisitely tender. Overlaps angle of the mandible does not extend to mastoid.

Orifice of Stenson’s duct is erythematous and swollen. No adenopathy, normal conjuctiva, chest clear. No rash.

Bloodwork

CBC: high lymphocytes. Otherwise unremarkable Lytes: N Creatnine: N Urea: N

DDx: Parotitis

MUMPS (30% of cases are unilateral) Viral infection:

Coxsackie, parainfluenza, influenza-A, EBV, adenovirus, HIV

Bacterial infection: Staphylococcus aureus, rarely gram negs or anaerobes

Non-infectious causes: Salivary calculus, tumour, Sjorgren's syndrome, sarcoid, thiazide

diuretics, DM, uremia, parotid cyst

Source: Harrison's Principles of Internal Medicine - 16th Ed. (2005)

Mumps: objectives

1. Epidemiology, clinical manifestations, diagnosis and management of mumps

2. Public health responsibilities in Calgary

Mumps

Mumps is an acute, systemic, self-limited, communicable viral infection whose most distinctive feature is swelling of one or both parotid glands.

Involvement of other salivary glands, the meninges, the pancreas, and the gonads is also common.

Single-stranded RNA virus (Paramyxovirus) for which humans are the only natural host.

Virus can be isolated from saliva, CSF and urine

Respiratory transmission

Mumps: Complications

* All can occur in the absence of parotitis Orchtitis

Most common non-parotid manifestation in post-pubertal males 20-38% of cases Mostly unilateral and rarely affects fertility

Oophritis 7% of post-pubertal girls

Aseptic Meningitis (1-10% of mumps cases) Common in both adults and children Variable onset Early CSF shows high PMN’s and low glucose After 24h, CSF appears viral

Mumps: Complications

Encephalitis

Deafness

GBS

Transverse myelitis

Pancreatitis, myocarcial involvement, arthritis, thyroiditis, interstitial nephritis

Mumps in pregnancy: increased chance of SA in 1st T

Mumps: Epidemiology

Current Canadian Outbreak: As of October 5 – 836 cases in Canada in 2007 9 provinces with confirmed cases:

5 in Alberta – median age 22 (18-25), 60% male Overall age range: 2-73 All cases linked to cases in the Maritimes or close contacts of

cases Majority of cases among young adults (12-40 years old)

Mumps: Manifestations

Incubation period is 14-18 days (range 14-25) Parotitis: 30-40% of cases Orchitis: 20-37% of cases Pancreatitis 2-5% of cases CNS involvement: 15% of cases Up to 20% are asymptomatic 40-50% have nonspecific or primarily resp symptoms

No chronic “carrier” state has been identified

Mumps: Diagnosis

Usually a clinical diagnosis. No blood work necessary Case Definition:

Acute onset of bilateral or unilateral tender, self-limited swelling of the parotid or other salivary gland lasting more than two days without other apparent cause

Virus recovered from saliva, throat and urine early (and CSF if meningitis)

Labs: CBC Amylase

Mumps: Diagnosis

In the absence of another diagnosis to rule out mumps, persons with clinically compatible mumps AND an established epidemiologic-link to a laboratory-confirmed case should be reported as confirmed cases

RT-PCR of oral secretions early in course is the preferred method of diagnosis

IgM is not sensitive in our population (immunized) IgG must be sampled acutely AND 10-14 days later

Negative test does not rule out mumps

Mumps: Treatment

Supportive Analgesics and warm or cold compresses Meningitis or pancreatitis may require admission for IV

hydration Orchitis are treated with ice and support of the scrotum No role for Mumps IG

Mumps: Public Health Actions

Ensure blood, NP swab and urine are collected and sent to provincial lab for IgM and IgG ELISA, RT PCR and viral culture

*Oral swab collected for PCR in the first three days of symptoms is the preferred specimen

Cases are to self-isolate for 9 days following the onset of symptoms (swelling)

Mumps: Physician PH Responsibilities

Physicians shall notify the MOH about all confirmed cases within 48 hours via mail, fax or electronic transfer. “Confirmed case”:

Isolation of mumps virus from an appropriate clinical specimen

Significant rise or seroconversion in serum mumps IgG titre

Serum positive for mumps IgM antibody

Clinical illness in a person linked to a lab-confirmed case

Mumps: Vaccine

In Alberta – Children should receive MMR at 1 and 4-6 years of age ( 2 doses routine since 1982)

Because of timing of legislative changes, there are some individuals between ages of 12 and 19 who may have only had one dose

Safe for people with egg allergies In March 2004, 10 of the 12 researchers in original

autism paper published a retraction in the Lancet stating that "no causal link was established between MMR vaccine and autism as the data were insufficient"

Questions?