Interesting Case Rounds: “Sweet Cheeks”

1. Interesting Case Rounds: “Sweet Cheeks” James Huffman PGY-2 Emergency Medicine October 11, 2007 Thanks to Dr. Arun Abbi

2. 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

3. 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.

4. Bloodwork • CBC: high lymphocytes. Otherwise unremarkable • Lytes: N • Creatnine: N • Urea: N

6. 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)

7. Mumps: objectives • Epidemiology, clinical manifestations, diagnosis and management of mumps • Public health responsibilities in Calgary

8. 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

9. 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

10. Mumps: Complications • Encephalitis • Deafness • GBS • Transverse myelitis • Pancreatitis, myocarcial involvement, arthritis, thyroiditis, interstitial nephritis • Mumps in pregnancy: increased chance of SA in 1st T

11. 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)

12. 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

13. 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

14. 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

15. 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

16. 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)

17. 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

18. 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"

19. Questions?