What are the diagnosis and management recommendations for a patient with mumps parotitis, considering demographics and potential complications?

Mumps Parotitis: Diagnosis and Management

Diagnosis

Laboratory confirmation is strongly preferred over clinical diagnosis alone, as parotitis has multiple infectious and noninfectious causes and only 30-40% of mumps infections produce typical acute parotitis. 1, 2

Clinical Presentation

• Parotitis is NOT present in all cases—15-20% of infections are completely asymptomatic and up to 50% present with nonspecific or respiratory symptoms only 1, 3
• When present, parotitis may be unilateral or bilateral and can be preceded by several days of nonspecific prodromal symptoms including fever, headache, and malaise 4
• Rare presentations include synchronous involvement of parotid and submandibular glands 5

Laboratory Confirmation Criteria

• Isolation of mumps virus from clinical specimens (saliva, urine, cerebrospinal fluid, or serum) 2, 6
• Significant rise in serum mumps IgG antibody between acute and convalescent specimens 2
• Positive serologic test for mumps IgM antibody 2
• Reverse transcriptase-polymerase chain reaction (RT-PCR) from parotid duct swab, saliva, or other specimens 6, 5

Critical Diagnostic Caveat

• Do not assume immunity based on vaccination history alone—recent outbreaks have occurred in highly vaccinated populations, particularly among young adults in college settings 1
• Clinical diagnosis of mumps is unreliable and should not be considered in assessing immune status 7

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Management

The American Academy of Pediatrics and CDC recommend supportive care only for mumps treatment, focusing on symptom control, strict isolation for 5 days after parotitis onset, and vigilant monitoring for complications that are significantly more severe in adults. 1, 2

Immediate Symptomatic Management

• Provide acetaminophen or NSAIDs for pain and fever control to manage fever, headache, and parotid gland pain 1, 2
• Ensure adequate hydration and fluid intake, as parotitis makes swallowing uncomfortable and painful 1, 2
• Recommend soft foods and avoidance of acidic foods that may stimulate salivary flow and worsen parotid pain 1, 2

Mandatory Isolation Requirements

• Implement droplet precautions immediately and isolate the patient for 5 days after onset of parotitis 7, 1, 4
• Patients are contagious from 7 days before through 8 days after parotitis onset 1, 2
• Use standard precautions plus droplet precautions (gown and gloves for patient contact); negative pressure rooms are NOT required 7
• Report probable or confirmed cases immediately to state and local health departments 1, 2

Monitoring for Complications (More Common and Severe in Adults)

Adults require heightened surveillance as complications are significantly more common and severe than in children. 1, 2

Neurologic Complications

• Aseptic meningitis (occurs in 4-6% of cases): Monitor for severe headache, neck stiffness, photophobia, or altered mental status 1, 2
• Encephalitis: Watch for seizures, paralysis, or cranial nerve palsies, which can cause permanent sequelae 1, 2
• Hearing loss: Assess for sudden sensorineural deafness, which can be bilateral and permanent—mumps was a major cause of childhood deafness in the pre-vaccine era 1, 2

Reproductive Complications

• Orchitis in postpubertal males (occurs in up to 38% of cases): Assess for testicular pain and swelling, though sterility is rare 1
• Oophoritis in postpubertal females: Monitor for pelvic pain from ovarian inflammation 1, 3

Other Complications

• Pancreatitis: Watch for severe abdominal pain, nausea, and vomiting 1, 2

Special Management for Facial Nerve Involvement

If facial droop or weakness develops, initiate corticosteroid therapy promptly with prednisone 1-2 mg/kg/day for 5-7 days followed by a taper over 5-7 days to reduce inflammation and improve nerve function. 1, 2, 3

• Provide eye protection to prevent corneal damage if facial weakness prevents complete eye closure 1, 2, 3
• Reassure patients that complete recovery occurs in approximately 70-80% of cases within 3-6 months 1, 3

Management in Pregnancy

• Treatment follows the same supportive care principles with acetaminophen or NSAIDs for pain control, hydration, and soft foods 2, 3
• Do NOT administer mumps vaccine to pregnant women due to theoretical risk of fetal harm from live-virus vaccine 1, 3
• Mumps infection during first trimester increases risk for fetal death but is NOT associated with congenital malformations 2, 3

Healthcare Setting Outbreak Control

• Only healthcare personnel with adequate presumptive evidence of immunity should be exposed to patients with mumps 7
• Healthcare personnel with no evidence of mumps immunity who are exposed should be offered the first dose of MMR vaccine and excluded from duty from day 12 after first exposure through day 25 after most recent exposure 7
• Healthcare personnel with mumps should be excluded from work for 5 days from onset of parotitis 7

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Common Pitfalls to Avoid

• Do not overlook complications in patients without parotitis—serious complications can occur without evidence of parotid swelling 1
• Do not assume MMR vaccine provides post-exposure prophylaxis—antibody response generally does not develop soon enough to provide effective prophylaxis after exposure, though vaccine should still be offered to protect against future exposure 7
• Do not use immune globulin for post-exposure prophylaxis—no evidence exists that it is effective 7
• Mumps disease is generally self-limiting, with most patients recovering without intervention beyond supportive care 1, 3