Puffy-faced Lineman - Page #4
 

Working Diagnosis:
Presumed mumps.

Treatment:
Isolated for 5 days. Local Health Department notified. Mumps titer came back negative. Back to team activity and asymptomatic in 10 days. Received call 2 days later. Right side of face now swollen and temp back. Seen at office. Vital signs stable. Exam negative except now tender on right side.

Author's Comments:
The patient is currently back playing football with no apparent problems. No one else on the team became symptomatic. There have been 2 other cases on campus thus far.

We followed CDC Guidelines on isolating the patient as soon as we suspected mumps. There current recommendation is to keep the patient isolated for 5 days, (best recommendation is to send them home) and return to activity when tolerated. There has been some discussion on keeping the patient isolated for 10 days but studies show that viral shedding after 5 days is very low. There have been a number of cases of wild type mumps noted in Illinois. Our question is what actually happened with this patient? Did he have 2 separate episodes or was he contagious throughout this time? For prevention of the rest of the team, we discussed possibly administering a third MMR.

Editor's Comments:
With the current skepticism regarding vaccines leading to resurgences of serious childhood illnesses, it is prudent to be familiar with such ailments and their local prevalence to more finely tune your clinical suspicion for them. Following the CDC guidelines and informing the local health department and campus health center, when appropriate, are vital ways to help reduce the likelihood of outbreaks. When providing care for a college or university, isolation may be logistically difficult to achieve. Hence, it may be helpful to establish a protocol to facilitate isolation for those unable to return home.

It is important to note that clinical diagnosis of mumps in an individual with parotitis is sufficient enough to initiate CDC guidelines and isolation measures.

When evaluating an individual with suspected mumps, it is essential to review the patients past medical history with emphasis on immunization records if available. Additional information that may be useful to further assess clinically diagnosed or suspected mumps include the following: serum amylase if abdominal pain, cramping, nausea or emesis is present; CBC with differential may reveal relative lymphocytosis in setting of leukopenia, and polymerase chain reaction (PCR) of cerebral spinal fluid, saliva and/or urine for rapid diagnosis in the setting of an outbreak or atypical, extrasalivary gland presentation such as aseptic meningitis. Viral cultures may be considered for the same specimens but are less sensitive and more time consuming.

Of note, up to 20 percent of cases of mumps may have an asymptomatic or subclinical presentation, which is more common in the adult population. As treatment for mumps is primarily supportive, this does not likely pose a significant risk to those affected but may contribute to further viral spread.

The patient's acute presentation of contralateral parotitis is atypical. Re-implementing CDC guidelines including isolation precautions is prudent. In light of the presumed recurrence and potential for associated complications, it is reasonable to consider extending the isolation to a 10 day period. Prior to return to play, one may consider obtaining an electrocardiogram, especially if the patient has a baseline study for comparison or history of cardiac pathology, as there have been rare but rapidly progressive and potentially fatal occurrences of myocarditis with dilated cardiomyopathy. Given this athlete's chosen sport, it may beneficial to perform serial hearing and vestibular evaluations as it may help distinguish between an acute concussion and delayed complication of mumps (i.e. sensorineural hearing loss with vestibular dysfunction).

Acknowledgments:
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