Epidemic Parotitis

EPIDEMIC PAROTITIS, parotitis epidemica (mumps), is an acute contagious infectious disease that occurs epidemically, with a characteristic localization in the salivary glands, primarily the parotid gland ("mumps"). The swelling of the parotid glands observed in this condition can be unilateral or bilateral, is for the most part benign in nature, and significantly alters the patient's face (hence the name "mumps" in English, "ourle" in French, and "Bauernwetzel" or "Ziegenpeter" in German). The disease occurs sporadically, but more often, as the name itself suggests, in the form of epidemics that spread slowly over many weeks and months, and it primarily affects children. History. Epidemic parotitis has been known for a long time and was described by Hippocrates, who noted its characteristic features: a mild course, the absence of suppuration in the parotid glands, and inflammation of the testicles (orchitis) as a specific complication. For a long time, epidemic parotitis was confused with secondary changes in the parotid gland and was not clearly distinguished as an independent disease. The study of mumps epidemics by a number of authors, beginning with Hirsch (1714), was of enormous importance. The clinical picture of the disease was gradually clarified, but some researchers still classified epidemic parotitis as a group of local contagious diseases (Niemeyer, Soltmann). Only later work (including the work of Filatov) clearly and firmly established that mumps is not a contagious inflammation of the salivary glands, but a general infectious disease. Etiology. The causative agent of epidemic parotitis has not yet been precisely established. Numerous attempts by authors to find the causative agent have been described in the literature. A number of authors have found bacilli and diplococci in the blood, urine, and saliva of patients. In experiments on animals, it was possible to cause severe orchitis in dogs and rabbits, and inflammation of the parotid gland in monkeys and rabbits, using the isolated microorganisms. The observations of Gordon and Wollstein, who passed the saliva of patients through a Berkefeld filter, were of great importance. This filtrate was used by them in experimental inoculations. Wollstein caused typical parotitis in cats with it (1916). In Gordon's opinion, the filterable virus is apparently similar to the virus of Heine-Medin disease, smallpox, typhus, epidemic encephalitis, and rabies. It is destroyed at 55°. Recently, Kermorgant, through experiments on horses and rabbits, isolated a culture consisting of a symbiosis of a spirochete and a motile Gram-negative bacillus; the spirochete is 10-15 microns long with cilia at the end. A culture of this spirochete in the amount of 1/10 cm³, injected into Stensen's duct or directly into the parotid gland or testicle, caused bilateral swelling of the parotid glands or testicles after 7-10 days, according to Kermorgant's observations. In the blood of convalescents, especially those who had already suffered from epidemic parotitis, Kermorgant discovered the presence of lysin-agglutinins. Kermorgant found the same spirochete in the saliva of patients with rubella; thus, its specificity is questionable. Zoeller (1916) failed to isolate Kermorgant's spirochete in cases of epidemic parotitis. Thus, the causative agent of epidemic parotitis has not yet been definitively established. Epidemiology. The disease spreads slowly and gradually in groups, closed institutions, dormitories, children's homes, hospitals, sanatoriums, schools, barracks, and on ships. An epidemic is usually limited to a single house, apartment, or individual group. Children are most susceptible to infection. Essentially, epidemic parotitis belongs to the diseases of childhood and adolescence. According to data from various Russian and foreign authors, the largest number of cases falls in the age range from 5-6 years to 15. Cases under 1 year of age are a great rarity. Of extremely great interest are the apparently very rare cases of epidemic parotitis in newborns whose mothers had mumps during pregnancy. These cases indicate the possibility of intrauterine infection. The elderly also rarely get sick. Infection in the elderly is observed only in isolated cases. In adults, epidemic parotitis usually affects a younger age group (from 18-20 to 30-40 years). Apparently, adults are not as susceptible to mumps as children. Prolonged and close contact is required for infection. Of 330 cases studied by Kanevskaya, 91% of patients were under 16 years of age and only 9% were adults. In 200 cases studied by Figman, there were 50 adult patients. Profession in adults is of no importance; the main factor is social and living conditions: overcrowding, poor sanitary and hygienic conditions. Epidemic parotitis spreads mainly in the cold season and decreases sharply in the summer, which is possibly explained by greater overcrowding in winter; for example, according to Berdichevskaya and Kanevskaya, the majority of illnesses occur in the winter (in Kanevskaya's study, only 22 cases out of 363 occurred in the summer). Teissier noted 90 epidemics in the cold season against 20 in the summer. Sex plays no role. The pathogenesis of epidemic parotitis is still far from being studied. It has been established that a patient with epidemic parotitis is contagious in the first 4 days of the disease. Contagiousness then progressively decreases and ceases 3 weeks after the appearance of this disease. But some authors (Sharp) have noted, as an exception, cases of transmission of infection 6 weeks after the onset of the disease. Apparently, infection occurs directly from the patient. Some express the idea of droplet infection. Infection through third parties and objects is extremely doubtful. Once contracted, epidemic parotitis provides lifelong immunity. As a rule, mumps does not recur. Pathological anatomy. Due to the favorable course of the disease and the lack of autopsies, the pathological anatomy of epidemic parotitis has been very little studied. There are only isolated descriptions in the literature, but no summary conclusions. Pathological-anatomical changes boil down to the following: in the parotid gland, mainly directly around the ducts, inflammatory foci are found, representing round-cell infiltrates of irregular shape, less often clusters of epithelioid cells, for the most part surrounded by a lymphocytic zone. Even less often, one can notice the development of fibroblasts in them and the beginning of a transition into scar tissue. In the area of the round-cell infiltrates, the excretory ducts are more or less significantly dilated and filled with protein mass with a small admixture of cellular elements. No changes are noted in the epithelium of the glandular vesicles. The absence of suppurative processes is characteristic (in contrast to metastatic parotitis). Clinical picture. The incubation period ranges from 8 to 22-25 days. Usually, epidemic parotitis begins with slight malaise; very quickly, after a few hours (from 12 to 36), swelling appears in the area of the parotid gland. In the vast majority of cases, this short prodromal stage goes unnoticed, and only in some cases, especially during an outbreak of an epidemic in hospitals, is it possible to note restlessness or lethargy and apathy in children, rarely convulsions, vomiting, and nosebleeds, or loss of appetite. In older children and adults, there are complaints of headache, general malaise, and rarely muscle pain and chills. Already in this stage, one can observe angina in the form of diffuse hyperemia. In approximately 50% of cases, the sign of Mourson (1878) is noted, namely, a small protrusion in the form of a papilla on the mucous membrane of the cheek at the site of Stensen's duct, which is usually invisible; in the center of the papilla, the opening of the duct is visible, surrounded by a dark red hemorrhagic rim. In some cases, it can only be noticed by pulling back the fold of the mucous membrane. The Mourson sign is detected only on the side of the affected parotid gland. If the lesion also affects the other gland, it is also noted on the other side. After 4-5 days, the swelling of the papilla disappears without a trace. While a number of authors emphasize the importance of this symptom for early diagnosis, other authors deny the specificity of this symptom for parotitis, as they have also detected it in other diseases (influenza, angina). In exceptionally rare cases, stomatitis is observed. The temperature rises to 38-39° and higher, usually lasting from 3-5 to 7-10 days, depending on the severity of the disease and the resistance of the organism. In the first days, the swelling of the parotid gland is detected as a visible protrusion, clearly limited to the touch, of elastic-doughy consistency, and slightly painful. The skin is not changed. In older children and adults, in some cases, pain in the area of the parotid gland is observed even before the appearance of clear swelling. In the following days, the swelling loses its definite outlines due to the appearance of edema of the surrounding tissue. The edema spreads diffusely upwards (towards the eye) and downwards (towards the neck). Descending downwards, it fills the fossa between the ascending ramus of the lower jaw and the mastoid process. The earlobe is characteristically pushed out and raised forward and upward ("mumps"). Chewing is difficult and painful; in some cases, patients can open their mouths only with difficulty. The skin is tightly stretched, glossy, and shiny. The swelling never fluctuates. According to the observations of some authors, the left gland is more often affected. In the vast majority of cases (approximately 80%), after a short interval (from 2-3 to 7-8 days), the other parotid gland is also affected, and the characteristic "mumps" face is produced.

Chewing is very difficult at this time, and the pain reaches its maximum; the temperature, having dropped after the first 3-4 days, rises again. Usually, no cardiac lesions are noted. In older children and adults, in some cases, a slowing of the pulse is observed. The spleen usually does not react. As for the liver, here, especially in children, one can note slight swelling at the height of the disease, which quickly disappears. In some cases, diarrhea is noted. The blood picture is characterized by leukopenia (in children, the number of white blood cells drops to 2,000-4,000-5,000), neutropenia, lymphocytosis, and the appearance of monocytes. The urine is normal. After 3-4 days (sometimes 7-8 days) after the swelling of the second parotid gland, the disease begins to subside; the temperature gradually drops to normal, the swelling and pain decrease, chewing becomes free, and the patient recovers quickly. The swelling of the parotid gland slowly resolves and usually disappears after 2-3 weeks. In some cases, recovery is delayed for several weeks due to the involvement of other glands in the process. Among these, swelling of the submandibular glands is noted more often. In these cases, a dense, round tumor, painful upon pressure, is palpable under the horizontal ramus of the lower jaw, which gradually spreads toward the neck. Various combinations of swelling of the parotid and submandibular glands are observed, namely: swelling of one parotid and the ipsilateral or contralateral submandibular gland, or of two parotid and one or two submandibular glands. Primary swelling of the submandibular glands with subsequent involvement of the parotid is encountered less frequently. Cases of isolated swelling of the submandibular glands without involvement of the parotid are observed. Swelling of the sublingual glands is encountered even more rarely. In these cases, the edema spreads to the anterior surface of the neck and the submaxillary region. The lacrimal glands are involved in the process least of all. Forms of the course of Epidemic Parotitis. Forms occurring with swelling of the parotid glands, as well as the submandibular ones, are encountered most frequently. They are observed predominantly in children. Their course is favorable, and the outcome is complete recovery. They are of mild and moderate severity. Among the former, very mild cases are observed with insignificant swelling of the parotid glands at a subfebrile temperature (formes frustes). Forms that give relapses at indefinite intervals—from a few days, 2-3 weeks to 2-6 months—are often noted, and there are isolated cases with a relapse after 1 year. The frequency of relapses depends on the nature of the epidemic and a number of other exogenous and endogenous causes, fluctuating on average from 4-6 and 7% to 10%. Chronic forms are exceptionally rare and are characterized by a protracted course and slow disappearance of the tumor; the submandibular glands are more often affected. Severe forms of Epidemic Parotitis are observed extremely rarely. They are accompanied by high temperature, are characteristic of a more adult age, and manifest with very rare symptoms specific to Epidemic Parotitis, incorrectly described as complications. Among these, the most frequent is the involvement of the testicles. Orchitis is observed no earlier than the period of puberty and mainly in adults. In children, it occurs in isolated cases. It is interesting to note that emaciated and starving children during the mumps epidemic in 1922-23 in Moscow never developed orchitis (Berdichevskaya). In adults, orchitis is more often observed at the age of 20-25 years. Usually, orchitis appears on the 6th-7th day of the disease, after the swelling of the parotid glands on the same or opposite side. Sometimes both testicles are involved in the process. In rare cases, primary involvement of the testicle is observed with subsequent swelling of the parotid gland. Orchitis manifests as pain in the testicular region, an increase in temperature to 39° and 40°, and swelling of the testicle, most often the left one. In the blood, the number of white blood cells increases (10,000-12,000), and neutrophilia appears. After 8-10 days, the temperature drops. When the other testicle is involved in the process, the temperature rises again. After inflammation, in some cases, atrophy of the testicle remains; with the involvement of both testicles, azoospermia may result. The frequency of orchitis depends on the severity of the epidemic and a whole series of other factors; therefore, the figures cited by authors vary: from 4, 10, 20% to 50% and even more. In isolated, extremely rare cases in adult women, the ovaries are affected. On the 5th-7th day after the swelling of the parotid glands, pain appears deep in the iliac fossae on one or both sides. The temperature rises. Upon examination, it is possible to palpate enlarged ovaries. In girls, oophoritis is encountered very rarely at the age of 9-15 years (Troitsky), i.e., during the period of puberty. In view of the rarity of the diseases, there are almost no summary and long-term observations. There are indications of atrophy of these organs. Even more rarely in women, involvement of the mammary, Bartholin's glands, and labia majora is noted. Involvement of the pancreas is exceptionally rare, especially in children. Abdominal pain and sensitivity upon pressure on the pancreatic region give rise to the assumption of pancreatitis. Cases of diabetes that developed after Epidemic Parotitis have been described. Even rarer are cases of involvement of the thyroid and thymus glands. Exceptional cases are observed with involvement of the meninges, meningitis, encephalitis (with focal changes), and meningoencephalitis. They appear on the 4th-5th day after the swelling of the parotid gland with elevated temperature and are accompanied by delirium, loss or clouding of consciousness, convulsions, headache, neck stiffness, Kernig's sign, and increased knee reflexes. As a characteristic symptom, slowing of the pulse is noted. The number of beats in adults reaches 52-48. Examination of the cerebrospinal fluid gives a positive Pandy reaction and pleocytosis from 25 to 60; lymphocytes predominate. In meningoencephalitis, paralyses are observed: mono- and hemiplegia, ptosis, anisocoria, strabismus, involvement of the cranial nerves, facial nerve, hypoglossal nerve, etc. These phenomena usually disappear after 5-10 days, especially in children. In adults, in exceptional cases, death occurs. Peripheral neuritis is also rare. Regarding the psyche, in severe cases, confusion and acute psychosis are observed, which pass quickly. Complications involving the sensory organs are even rarer. Regarding the organ of vision, optic neuritis, iritis, blepharitis, and keratoconjunctivitis are observed. Regarding the organ of hearing, acute sudden involvement of the inner ear (labyrinthitis) occurs. It appears in the first days of Epidemic Parotitis, manifests as headache, dizziness, general severe malaise, ear pain, and then loss of consciousness. Persistent deafness develops rapidly. After a few days, the acute phenomena pass, and the swelling of the parotid glands becomes clearly marked. Deafness after Epidemic Parotitis is apparently analogous to deafness after cerebrospinal meningitis and is also incurable. In severe cases of mumps, at the beginning of the disease, various kinds of toxic rashes are sometimes noted on the skin: measles-like, scarlet fever-like, papular, and spotted erythema, which disappear quickly. Non-specific rare complications of severe cases of Epidemic Parotitis include kidney lesions in the form of acute hemorrhagic transient nephritis; lung lesions (lobular pneumonia) and, rarely, pleurisy and diarrhea. Regarding the circulatory organs (as an exceptional rarity), endopericarditis is described, since the heart, as a rule, is not affected in Epidemic Parotitis. Finally, unstable arthritis and joint pain are mentioned in the literature. In rare cases, severe tonsillitis, otitis, and laryngeal edema are observed. The liver and spleen swell slightly in severe cases. In the blood in these cases, one observes not leukopenia, but leukocytosis with a characteristic predominance of monocytes. The diagnosis of Epidemic Parotitis in ordinary cases is not difficult. Epidemic Parotitis can be confused with cervical lymphadenitis in acute infections (diphtheria, scarlet fever). But in Epidemic Parotitis, there is a typical primary swelling in front of the ear of a doughy consistency, not sharply limited, not fluctuating, with normal skin, and with a favorable course. In lymphadenitis, the glandular tumor is denser, and it appears secondarily, with the clinical picture of the underlying disease; there is redness of the skin, sometimes fluctuation and greater tenderness, and finally, the localization of the tumor is different. Erysipelas, located in front of the ear, is also easily excluded on the basis of typical redness of the skin, local increase in temperature, tenderness in the area not characteristic of the parotid glands, and the severity of the course. Metastatic parotitis is observed in acute infections (typhoid and typhus, diphtheria, sepsis, etc.). They are mostly unilateral, result in suppuration, and appear secondarily with the characteristic symptom complex of the underlying disease. Toxic parotitis is encountered in acute or chronic poisoning with lead, mercury, or iodine. They are accompanied by changes in the oral mucosa, proceed slowly, and do not have the cyclic course of Epidemic Parotitis. The diagnosis of atypical cases of primary swelling of the submandibular glands and testicles is more difficult. Subsequent swelling of the parotid glands or the presence of Epidemic Parotitis in the family reveals the true etiology of the disease in these cases. Parulis gives a different localization of the tumor and tenderness and a different character of temperature. Tuberculosis of the parotid glands and malignant tumors of it are extremely rare phenomena, are not bilateral, and give a different symptom complex (see).

(parotid gland). Orchitis in other diseases (smallpox, Malta fever, etc.) is secondary and accompanied by characteristic symptoms. The cerebral phenomena in Epidemic Parotitis are characterized by the rapid disappearance of meningeal symptoms and severe accompanying phenomena (paralysis), bradycardia, and lymphocytes in the cerebrospinal fluid. The prognosis is generally favorable. In severe cases, besides the usual factors, the age factor is significant: severe forms are encountered more often in adults. In children, the disease proceeds so favorably that children's hospitals do not know of any fatal cases. Thus, according to autopsy data from the Model Children's Hospital in Moscow (M. A. Skvortsov), out of 11,715 autopsies from 1911 to 1931, there was not a single case of death from Epidemic Parotitis. According to Ringberg's statistics, out of 58,337 cases of Epidemic Parotitis, 7 deaths were noted; according to English authors from 1891 to 1910, the mortality rate was 0.3%. Prevention and treatment. In view of the fact that Epidemic Parotitis proceeds slowly and affects dormitories, hospitals, etc., for a long time, broad, persistently conducted prevention is necessary. Upon the first appearance of a case of Epidemic Parotitis, it is necessary to carefully isolate the patient for a period of no less than 21 days. To avoid the penetration of infection—a thorough and detailed questioning of everyone admitted to the hospital regarding cases of mumps in school or the family. It is necessary to take sanitary-hygienic measures in relation to the premises and the collective located within it. It is necessary to persistently ventilate the premises, carefully monitor cleanliness, destroy dust, cobwebs, dirt, monitor the cleanliness of bedding and linens, set up individual care items, separate dishes, organize long stays for children in the open air, etc. Thorough examination and care of the mouth and skin is conducted for all members of the collective. Recently, cases of serotherapy during outbreaks of Epidemic Parotitis have been described in Soviet and foreign literature. Convalescent serum is injected under the skin, into a muscle, or into a vein. According to the authors' observations, Epidemic Parotitis in adults proceeded after this without severe complications. But this question is still in the stage of study, and there are no precise conclusions yet. Treatment consists of bed rest during the febrile state. Local treatment is not required. Some apply heat in the form of dry cotton wool or a camphor compress.