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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 32  |  Issue : 3  |  Page : 224-226

A case of mumps orchitis without parotitis in a vaccinated postpubertal male


Internal Medicine, NSMC Salem Hospital, Salem, MA, USA

Date of Web Publication11-Feb-2019

Correspondence Address:
Dr. Ahmed Elantably
10 Heritage Dr., Apt 37, Salem, MA 01970
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jms.jms_26_17

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  Abstract 

Mumps is a viral infection of the salivary glands that commonly present as unilateral or bilateral parotitis usually during childhood. Serious complications of mumps include meningitis/encephalitis, as well as orchitis in adolescent boys and adult men. We report a case of a 29-year-old male patient with mumps-associated bilateral epididymo-orchitis without signs of parotitis. The diagnosis was confirmed clinically and serologically by IgG and IgM titers.

Keywords: Epididymo-orchitis, mumps, orchitis


How to cite this article:
Elantably A, Oommen VV. A case of mumps orchitis without parotitis in a vaccinated postpubertal male. J Med Soc 2018;32:224-6

How to cite this URL:
Elantably A, Oommen VV. A case of mumps orchitis without parotitis in a vaccinated postpubertal male. J Med Soc [serial online] 2018 [cited 2019 Apr 19];32:224-6. Available from: http://www.jmedsoc.org/text.asp?2018/32/3/224/251990


  Introduction Top


Mumps is a viral infection frequently accompanied by manifestations of nonspecific prodrome of low-grade fever, malaise, headache, myalgia and anorexia, followed within 48 h by parotitis, which is a classic feature, present in 95% of symptomatic cases of mumps, due to direct infection of ductal epithelium and local inflammation, and can last up to 10 days. Asymptomatic infection occurs in 15%–20% of cases and nonspecific or predominantly respiratory symptoms are seen in up to 50% of cases in whom the diagnosis of mumps is not usually made. The more serious complications of mumps, such as meningitis, encephalitis, and orchitis, may occur in the absence of parotitis, which can delay accurate diagnosis of the clinical syndrome. Epididymo-orchitis, the most common complication of mumps infection in the adult male, may develop in up to 38% of infected post pubertal males. Symptoms are characterized by the abrupt onset of fever from 39°C to 41°C and severe testicular pain, accompanied by swelling and erythema of the scrotum. While testicular atrophy has been documented in as many as 30%–50% of patients following mumps orchitis and impaired fertility in approximately 13%, sterility is estimated to be rare. The risk of sterility is higher in men who have bilateral orchitis. A possible association between mumps orchitis and the subsequent development of testicular cancer has been evaluated in several retrospective case series. Despite the interest and attention which have been directed to the disease, there is comparatively a little knowledge regarding orchitis associated with mumps without parotitis.


  Case Report Top


A 29 year old male with no significant past medical history presented with 3 day history of progressively worsening fatigue associated with headache and sore throat. He presented to the urgent care the night before with the same symptoms. He was given ibuprofen without improvement. He described a sore throat was so severe that it hurts when he drinks even water. He has body aches and generalized weakness that made him unable to open the water tap in the morning, as well as testicular pain. He described a headache as bifrontal, band-like, constant, in his eyes. He is not a headache person at baseline. He had some nausea no vomiting. He traveled to Aruba 1 month ago and denies any tick bites or sick contacts. He had chills, no fever, night sweats, or weight loss. He denies syncope, seizure, or change in the vision or speech. No cough, chest pain, shortness of breath, palpitations, paroxysmal nocturnal dyspnea, or change in bowel habits. No urinary symptoms. No focal limb weakness, numbness, or speech problem. No skin rash.

He works in construction as a carpenter. He is married and has a 9-month-old infant at home. The patient is monogamous with one female partner and does not use protection. He denies any new sexual contacts. He does not use tobacco products, but he uses marijuana daily for recreation. He drinks a couple of beers after work. He had a recent coloring of his tattoo on his right arm; he always goes to the same tattoo shop where they use a sterilized kit, which is always opened in front of him. His vaccination history is all complete, including vaccination against mumps, rubella, and measles.

In the Emergency Department, the patient's blood pressure was 130/69, pulse rate was 104, respiratory rate was 18, and temperature was 99.4 F. Pulse oximetry is 98% on room air. The patient received 1 L of normal saline and 2 g of IV ceftriaxone. He was tested for HIV, which came back negative. Chest X-ray was normal.

On examination, he is a well-developed, well-nourished muscular male who is in no acute distress. Sclera is anicteric. Mucous membranes are pink and moist. The neck is supple. There is no palpable lymphadenopathy in the anterior, posterior cervical, supraclavicular, or axillary chains. He has a faint blanching rash on the posterior neck region. He is noted to have a tattoo on his right upper extremity and back, with no signs of erythema or infections. On genito-urinary examination, he is a circumcised male. No urethral discharge noted. Testes are descended bilaterally, with swollen erythematous scrotum, and bilateral tenderness in the testes and on tethering of his epidydimal cord.

His temperature rose to 100.4 F. The patient had worsening headache and neck stiffness. Neurology recommended doing a head computed tomography (CT) scan before the lumbar puncture. The CT scan came back normal. Lumbar puncture was done which came back clean, showing a negative Gram stain and no organisms. The viral panel was sent, including Epstein–Barr virus (EBV), cytomegalovirus (CMV), and mumps were sent to the state laboratory, which was pending at the time of admission. The patient received intravenous (IV) ceftriaxone and doxycycline.

ID was consulted which recommended continuing the doxycycline and stopping the ceftriaxone. The patient was improving day-by-day and on the day of discharge regained most of his strength, and he was moving around. His generalized malaise and aches got better. On physical examination, he was stable, maintaining saturation on room air. His testicular erythema, swelling, and tenderness were gone.

The patient was on as needed pain medications, and antibiotics were stopped on discharge, and he was on IV Ringer's lactate. The patient was instructed to avoid contact with his 9-month-old infant until the results of the mumps result come back from the state laboratory and reported to his primary care physician.

There were also some pending tests at the time of discharge, including screening tests for systemic lupus erythematosus, EBV, CMV, and tick-borne disease like Lyme' s and Ehrlichia, and mumps serology immunoglobulin (Ig) G and IgM, as well as viral culture, which needed to be sent for the state laboratory. The patient was feeling better at the time of discharge. He was discharged home with no antibiotics. Later, the results came out from the state laboratory positive for mumps infection. In context to the incubation period of mumps, the patient was advised to keep away from the infant for at least 1 week after discharge.


  Discussion Top


In the United States, the incidence rate of mumps is several hundred to thousands of cases a year, most generally seen among college students who have a high vaccination rate.[1] The infection is spread from person-to-person through direct contact of respiratory droplets or saliva of an infected person, contaminated fomites or trans placental infection from mother to fetus, with the incubation period being about 12–25 days.[2] The patient is infectious from 3 days before 4 days after the onset of the illness.[2] The virus replicates in the nasopharynx, and regional lymph nodes with subsequently spread to multiple sites.[3] Up to 70% of patients develop symptoms of parotitis, which could be either unilateral or bilateral, and generally tender to palpation. Nonspecific prodromal symptoms include a low-grade fever, malaise, headache, and respiratory symptoms. About 15%–50% of cases may present with orchitis, generally in post pubertal males, but sterility is rare. Less common, but more serious complications include aseptic meningitis, encephalitis, and pancreatitis. Interestingly, mumps is one of the most common causes of acquired unilateral sensorineural hearing loss.

Diagnosis can be made clinically, given the characteristic parotid gland swelling, with confirmation made with the detection of IgM antibodies in acute infection, positive mumps viral culture or virus detection by reverse transcriptase-polymerase chain reaction from buccal and oral swab samples.[2]

The mainstay of treatment is supportive care as there is no specific antiviral therapy currently available, with the patients placed on droplet precautions and isolated for 5 days after the onset of parotitis.[4] As preventative measures, routine vaccination with the combination measles, mumps, and rubella (MMR) vaccine is recommended for most people 12 months or older.[4] Currently, no strong evidence exists for MMR vaccine for post exposure prophylaxis. The vaccine efficacy is about 88% with the administration of two vaccine doses, but the immunity can diminish over a prolonged period.[4]


  Conclusion Top


Mumps orchitis is a serious complication in post pubertal males which can happen without mumps parotitis. It is important to have a low threshold of suspicion even in vaccinated cases. However, the mainstay of treatment is supportive care.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Centers for Disease Control and Prevention. Mumps Homepage. Centers for Disease Control and Prevention; 10 August, 2016.  Back to cited text no. 1
    
2.
Hviid A, Rubin S, Mühlemann K. Mumps. Lancet 2008;371:932-44.  Back to cited text no. 2
    
3.
Centers for Disease Control and Prevention. The Pink Book. 13th ed. Atlanta, GA: Centers for Disease Control and Prevention; 2015.  Back to cited text no. 3
    
4.
McLean HQ, Fiebelkorn AP, Temte JL, Wallace GS; Centers for Disease Control and Prevention. Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: Summary recommendations of the advisory committee on immunization practices (ACIP). MMWR Recomm Rep 2013;62:1-34.  Back to cited text no. 4
    




 

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