The third in our new series which takes you through a detailed case history, describing the key principles of care before offering a take home message.
A 22-year-old man seeks medical attention at his university health centre. He had been in excellent health until one week earlier, when he noted onset of fever, headache, and malaise. After a few days, pain and swelling developed on the left side of his neck beneath the angle of the jaw. His illness became severe enough that he missed classes. He denies cough and sputum production, and he has not had any GI symptoms. He has pain on swallowing in the same area as the external neck pain and swelling, but he says this is not the pain he typically experiences with a sore throat.
The patient takes no medications. He drinks alcohol on weekends but otherwise does not drink excessively and does not use illicit drugs. One or two students in his halls of residence have been ill recently, but he is not sure of their specific symptoms or diagnosis.
Temperature is 38.7°C; heart rate, 92 beats per minute. Sclerae are injected. No redness, swelling, or exudates are noted in the pharynx, and the tonsils are normal and symmetrical. 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; right side of the neck is normal. The remainder of the physical examination is normal.
Results of routine laboratory studies, including a complete full blood count and biochemistry profile, are normal.
Which of the following statements about this patient is most likely to be true?
A. Results of a glandular fever screen be positive.
B. A throat swab will reveal streptococcal infection.
C. The complication rate associated with his illness is 5%.
D. A review of his vaccination history will reveal deficiencies.
Correct Answer: C
This young man has mumps. His symptoms fulfil the diagnostic criteria: acute onset of unilateral or bilateral tender, self-limiting swelling of the parotid or other salivary glands that lasts at least two days and has no other apparent cause.1
Several other diseases that are common in young adults also involve febrile pharyngitis or adenopathy. Pharyngitis is a nearly universal symptom of mononucleosis in this age-group. However, impressive tonsil swelling and severe exudative pharyngitis are the rule in mononucleosis; their absence here makes that diagnosis unlikely (choice A).
Although the physical findings in streptococcal pharyngitis (choice B) can be more subtle than those associated with mononucleosis, patients typically have a much more specific history of pharyngitis than was seen here. Also, a leucocytosis would be expected, and this young man's white blood cell count was normal.
Mumps used to be a common childhood illness, but declined markedly after the introduction of the MMR vaccine in 1988. The incidence has increased in recent years, probably because of media scares about the MMR vaccine. Mumps is unlikely, though possible in patients who have received the MMR – hence choice D is not necessarily true.
Clinical findings in mumps
The patient's neck pain was not pharyngitis but 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%. 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-limiting; however, complications do occur in 5% of patients (choice C). Orchitis is by far the most common of these; the more serious complications—meningitis, encephalitis, and deafness— occur in about 1% of patients.1
Outcome of this case
A clinical diagnosis of mumps was made, and the patient was given paracetamol for his fever and pain. No complications developed. His condition slowly improved over the ensuing week, and he was able to return to classes.
Suspect mumps in a young adult who, regardless of vaccination status, lives in close proximity to others his or her own age and presents with an inflamed parotid, or other salivary, glandWhat's the take home?