What's the Take Home?

Fever and Neck Pain in a College Student

Volume 59 - Issue 7 - July 2019

Author:
Ronald N. Rubin, MD—Series Editor

Citation:
Rubin RN. Fever and neck pain in a college student. Consultant. 2019;59(7):202-203, 224.

 

A 22-year-old man seeks medical attention at his college’s infirmary. He had been in excellent health until 1 week earlier, when he had noted the onset of fever, headache, and malaise. After a few days, pain and swelling had developed on the left side of his neck beneath the angle of the jaw. His illness had become severe enough that he had missed classes. 

He denies cough and sputum production, and he has not had any gastrointestinal tract symptoms. He has pain on swallowing in the same area as the external neck pain and swelling, but he says this is not the kind of pain he typically experiences with a sore throat.

The patient takes no medications. He drinks alcohol on weekends at parties but otherwise does not drink excessively and does not use illicit drugs. One or two students in his dormitory have been ill recently, but he is not sure of their specific symptoms or diagnosis.

On physical examination, his temperature is 38.7°C, and his heart rate is 92 beats/min. The sclerae are injected. No redness, swelling, or exudates are noted in the pharynx, and the tonsils are normal and symmetric. His neck is exquisitely tender on the left side, with swelling in the angle of the left jaw. No enlarged cervical or supraclavicular lymph nodes are palpable on the left; the right side of the neck is normal. The remainder of the physical examination findings are normal.

Results of routine laboratory studies, including a complete blood count and a chemistry/biochemistry profile, are normal.

Answer: B, a third dose of MMR vaccine in the at-risk population will likely aid in control of sporadic mumps outbreaks.

 

This young man has mumps, a disease recently thought to have been nearly eliminated in the United States. His symptoms fulfill the Centers for Disease Control and Prevention’s case definition of mumps: acute onset of unilateral or bilateral, tender, self-limited swelling of the parotid or other salivary gland that lasts at least 2 days and has no other apparent cause.1

MUMPS RESURGENCE AND LESSONS LEARNED

Mumps has had a resurgence in the United States despite the excellent early efficacy of the Jeryl Lynn strain mumps vaccine in children.2 This vaccine logarithmically reduced mumps cases, but outbreaks began to occur after a decade of use, prompting the recommendation for a second dose. Administration of the second dose nearly eliminated mumps between 1990 and 2006.

Then, in 2006, a series of outbreaks occurred on college campuses in the United States.1 These epidemics were studied in detail, revealing the following information:

  • The strain of mumps virus involved was mainly genotype G, a common strain against which the mumps vaccine is effective; thus, the resurgence was not caused by a new or resistant strain of mumps virus.
  • Among US adolescents, 87% had 2-dose coverage in 2006, which should have been adequate to provide herd immunity and thus prevent outbreaks or epidemics.
  • In more recent epidemics, again vaccination coverage approaching 90% was present in the index populations.3 (Thus, Answer D, which implies that this patient had not been properly vaccinated, is probably false.)

This patient is typical of those involved in the reported outbreaks. He had received 2 doses of the mumps vaccine—one in childhood and one in adolescence. Most likely his immunity had decayed in subsequent years, and when in college, in close proximity to others with a similar immune status, he was susceptible to contracting the disease.

CLINICAL FINDINGS IN MUMPS

The patient’s neck pain was not pharyngitis, but rather unilateral parotitis. In 92% of patients with mumps, parotitis is the salient clinical manifestation of the disease, with other salivary glands involved in the remaining 8% of cases. Salivary gland inflammation is more common than viral constitutional symptoms, which occur in about 60% of patients.1

For the most part, the illness is self-limited; however, complications do occur in up to 7% of patients (thus, Answer C is false).3 Orchitis is by far the most common of these; the more serious complications—meningitis, encephalitis, and deafness—occur in about 1% of patients.1,3

What is new and evolving from more recent epidemics relates to epidemiology and the potential for containment of sporadic epidemics. Elegant detailed epidemiology was reported in the 2009-2010 epidemic involving Orthodox Jewish communities. As usual, even in this closed population, vaccination status was very satisfactory, approaching 90%.3 Yet an epidemic was sustained despite this. The authors postulated two factors to explain this. First is the intense, close, and prolonged interpersonal contact in the chavrusa style of study in these religious academics. Such epidemiology to a lesser extent explains the propensity of sporadic epidemics in college campuses and dormitories. And second, there is decay in the immunity conferred by the MMR vaccination after a decade or more, such that the very same epidemiologic group—young adults—is once again affected.

A more recent paper took the next logical step, which was to administer a third dose of the MMR vaccine to essentially all (94%) students at the University of Iowa (and it should be noted that the pre-epidemic vaccination rate was 98.1%) during the vaccination campaign.4 This strategy resulted in a clear reduction in mumps attack rates. This study also demonstrated, using documented vaccination histories, the truth of the waning immunity theory previously mentioned. This third MMR vaccination has been actively used during the current Temple University outbreak in Philadelphia, as well, and seems quite effective control of these sporadic outbreaks.4 Thus Answer B is the most accurate statement here.

Answer A is not correct. In addition to the two described epidemics discussed,1,3 another study on measles in an Amish community also has shown that the index cases were people who had traveled internationally to countries where mumps and measles were still endemic, rather than there being a resurgence in endemic cases in the United States.5

An editorial comment on the vaccination controversy I cannot resist or ignore. There is great fuss currently regarding “antivaxxers” who adhere to an echo chamber of resonating disproven nonsense regarding autism risk as a “philosophic (which therefore must be accepted) reason” not to vaccinate their children. This is where the major antivaccination emphasis is arising, and not true religious proscription, despite that the references’ headings feature Amish communities, Orthodox Jewish Communities, and so on. Those communities had near-normal or at least significant vaccination rates, and the reason for lower vaccination numbers in the Amish community was not religious proscription but rather was isolation from hospitals and physician use and a lack of health insurance with resultant costs associated with vaccinations and health care participation in general! What a mixture of arrogant, misinformed entitlement in the antivaccination vigilantes and health care costs combining to impede the way of public health. We must all hope for no significant changes in virus antigenicity in the usual viruses—mumps, measles, influenza—let alone poliomyelitis, lest we really then inherit the wind, medically speaking.

PATIENT FOLLOW-UP

A clinical diagnosis of mumps was made, and the patient was given acetaminophen for his fever and pain. No complications developed. His condition slowly improved over the ensuing week, and he was able to return to classes.

TAKE-HOME MESSAGE

Suspect mumps in a young adult who, regardless of vaccination status, lives in close proximity to others his or her age and presents with an inflamed parotid or other salivary gland. Mumps outbreaks continue to sporadically occur in the United States due to a combination of factors including 1) the decay of immunity with time since vaccination; 2) common epidemiology of susceptible individuals in close contact, such as religious schools, communes, and dormitories; and 3) importation of index cases from international travelers from countries where endemic mumps continues. Mumps is not a trivial illness, with complications and requirement for hospital care approaching 7%. In the more recent outbreaks, the administration of a third dose of the MMR vaccine has demonstrated efficacy in diminishing frequency of spread and severity of illness.

Ronald N. Rubin, MD, is a professor of medicine at the Lewis Katz School of Medicine at Temple University and is chief of clinical hematology in the Department of Medicine at Temple University Hospital in Philadelphia, Pennsylvania.

References:

  1. Dayan GH, Quinlisk MP, Parker AA, et al. Recent resurgence of mumps in the United States. N Engl J Med. 2008;358(15):1580-1589.
  2. Centers for Disease Control. Recommendation of the Public Health Service Advisory Committee on Immunization Practices: mumps vaccine. MMWR Morb Mortal Wkly Rep. 1977;26:393-394.
  3. Barskey AE, Schulte C, Rosen JB, et al. Mumps outbreak in Orthodox Jewish communities in the United States. N Engl J Med. 2012;367(18):1704-1713.
  4. Cardemil CV, Dahl RM, James L, et al. Effectiveness of a third dose of MMR vaccine for mumps outbreak control. N Engl J Med. 2017;377(10):947-956.
  5. Gastañaduy PA, Budd J, Fisher N, et al. A measles outbreak in an underimmunized Amish Community in Ohio. N Engl J Med. 2016;375:1343-1354.