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Mumps: a resurgent disease with protean manifestations

Sanjaya N Senanayake
Med J Aust 2008; 189 (8): 456-459. || doi: 10.5694/j.1326-5377.2008.tb02121.x
Published online: 20 October 2008
Epidemiology: who is getting mumps today?

The estimated global incidence of mumps is 100–1000/100 000 population per year, with epidemic peaks every 2–5 years.3 In temperate climates, the peak incidence of mumps is in winter and spring, whereas cases can occur consistently throughout the year in tropical climates.4

Before the introduction of mass vaccination programs, mumps primarily affected 5–9-year-old children, but more recent (and large) outbreaks have mainly affected adolescents and adults.5,6 In 2004–2005 in the United Kingdom, more than 56 000 clinical cases of mumps were notified, with the majority of confirmed cases occurring in 15–24-year-olds.7 This change is clinically important, as mumps tends to be more severe in adolescents and adults than in children.8 Furthermore, some complications such as orchitis are limited to post-pubertal infection. Posters produced for mumps education campaigns in response to large Canadian outbreaks that also affected many adolescents and adults (http://www.health.alberta.ca/public/disease_conditions.html#mumps) are shown in Box 1.

In Australia, the National Notifiable Diseases Surveillance System (NNDSS) has recorded a consistent rise in mumps notifications over the past few years, with almost 600 notifications in 2007. NNDSS data show that notification rates in adolescents and young adults have increased over time, reflecting a similar pattern overseas. In 2007, 76% of mumps notifications in Australia were for people aged 20 years or older.9

The reasons for this change in mumps epidemiology are multifactorial. They include primary vaccine failure due to true immunological failure or administration of ineffective vaccine;5 secondary vaccine failure due to a loss of immunity despite initial seroconversion;10 and a lack of cross-neutralisation between vaccine strains and wild-type genotypes.1,11,12

Clinical features: how does mumps present?

The World Health Organization and the Centers for Disease Control and Prevention have the same clinical case definition for mumps:

Atypical and subclinical infection

While consideration of mumps is easy in the presence of parotitis, up to 30% of cases are asymptomatic and, of symptomatic cases, 10%–30% will not be associated with parotitis.8,13 This highlights the limitation of the case definition given above, which implies that swelling of the salivary glands is an essential diagnostic feature.

Diagnosis: what investigations may help?

Although mumps is probably the best known cause of bilateral parotitis, a number of differential diagnoses should be considered (Box 3). A suspected mumps infection can be confirmed by detection of antibodies to the virus, detection of viral RNA by reverse transcriptase-polymerase chain reaction (RT-PCR) techniques, or viral cultures of various clinical specimens. In Australia, mumps viral cultures are rarely performed. Serum, saliva and/or urine specimens may be useful in cases of uncomplicated mumps, but if mumps meningitis is suspected, cerebrospinal fluid (CSF) examination may be indicated.

Serum

Various techniques are available in Australia to detect antibodies to mumps, but the enzyme-linked immunosorbent assay (ELISA), or enzyme immunoassay, is probably the most commonly used.

IgM can be detected not only in primary mumps but even in secondary immune responses in cases of mumps due to secondary vaccine failure.12 While IgM may be detectable in serum as early as 11 days after exposure (before symptoms have appeared), the optimal time for detection is probably 7–10 days after the patient develops symptoms.19 However, the sensitivity of IgM testing is variable, being as low as 24%–51% in one study of five ELISA assays.26 Both false negative and false positive IgM results can occur. False negative IgM results may occur in people previously immunised or infected.27 In such settings, a rise in serum IgG titres may be a more useful indicator of current infection.19 False positive IgM results may occur after infection with parainfluenza viruses 1 and 3 or in the context of recent immunisation with vaccines containing a mumps component.27

Saliva

Both IgM and RT-PCR tests can be used to detect mumps in saliva. The salivary IgM test has high specificity (98%), and its sensitivity increases from 75% in the first week after symptoms appear to 100% thereafter.8 The RT-PCR test on saliva, which has a sensitivity of about 70%,28 is typically positive from 2–3 days before the onset of parotitis to 4–5 days afterwards,14 and thus can often detect mumps virus in saliva when the salivary IgM test is negative.

Urine

Mumps virus can be detected in the urine during the first 2 weeks of illness by RT-PCR testing.14 However, for reasons that are unclear, the RT-PCR test has a much lower sensitivity for urine specimens than for viral cultures. One study found the sensitivity of different PCR techniques to be as low as 2% and 29%.26

Cerebrospinal fluid

In mumps meningitis, the CSF characteristically demonstrates normal opening pressure; a normal cell count or lymphocytic pleocytosis (about 250 cells/mm3) (pleocytosis is present in about 50% of cases);24 an elevated protein level in two-thirds of cases; and a reduced CSF : serum glucose ratio (< 50%) in up to a quarter of cases.8 RT-PCR and antibody tests (IgG and IgM) can be used to detect mumps in CSF, with the former being more sensitive than the latter.29,30 At least one nested RT-PCR assay had a sensitivity of 96% in CSF, was highly specific and was positive for up to 2 years after infection.31 One study of mumps meningitis found that IgG and IgM could be detected in CSF at rates of 90% and 50% respectively.29

Prevention: the role of immunisation

In Australia, the measles–mumps–rubella (MMR) vaccine is currently recommended for children at the ages of 1 and 4 years. For adults who have only ever received a single dose of vaccine containing a mumps component, a second dose of MMR can be given at any age. As it is a live vaccine, its use is contraindicated for immunocompromised hosts.35 Short-term efficacy and seroconversion rates of about 90% are achieved after a single dose.4 The second dose of vaccine results in about 95% seroconversion, with a slower decline in antibody titres over time compared with subjects vaccinated only once.36 Immunogenicity and observational data tend to concur in showing that two doses of vaccine are more efficacious than one.37

In Australia, the Jeryl-Lynn strain of mumps vaccine is used.35 Despite being less efficacious and more expensive than the Urabe strain, its use is still cost-effective and less likely to cause vaccine-related aseptic meningitis.38

Apart from minor local reactions at the injection site, the major systemic reactions that may occur after mumps vaccination are low-grade fever, aseptic meningitis, meningoencephalitis and parotitis. Post-vaccine meningitis occurs 2–3 weeks after vaccination.4 The meningitis is mild to moderate in severity, and all reported cases have resolved completely within a week.39 The Jeryl-Lynn vaccine strain is associated with the lowest rate of vaccine-related aseptic meningitis, ranging from less than 1 case/525 312 doses to 0.1 cases/100 000 doses.3 Sensorineural deafness, orchitis and even post-vaccination pancreatitis have also been reported as extremely rare complications following vaccination.4,40

Conclusion

There has been a resurgence of mumps in recent times that is multifactorial in origin. More cases are occurring in older age groups than previously, meaning that cases of greater severity and/or with more complications, such as epididymo-orchitis and oophoritis, will be seen. Clinicians need to raise their awareness of the disease — in particular of its protean manifestations — and to be familiar with the available tools for diagnosis.

  • Sanjaya N Senanayake1

  • Department of Microbiology, Canberra Hospital, Canberra, ACT.



Competing interests:

None identified.

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