Mumps (mumps). Causes, symptoms, treatment and prevention. Acute mumps Purulent mumps mcb 10

ICD-10 was introduced into healthcare practice throughout the Russian Federation in 1999 by order of the Ministry of Health of Russia dated 05/27/97. No. 170

A new revision (ICD-11) is planned by WHO in 2017 2018.

As amended and supplemented by WHO

Processing and translation of changes © mkb-10.com

Parotitis (ICD-10 code: B26.8)

Inflammation of the parotid gland. In acute nonspecific parotitis, the causative agents of the disease are various microorganisms. Chronic nonspecific mumps is often the outcome of acute mumps.

The main tasks of laser therapy are to eliminate inflammation in the gland, improve its metabolism and microcirculatory hemodynamics, and optimize excretory activity.

The plan of therapeutic measures includes direct irradiation of the projection zone of the gland and areas of additional exposure, including: receptor zones located in the zygomatic and buccal regions of the face, exposure to the dorsum of the hand and the inner surface of the forearm, the outer surface of the lower leg, foot.

Modes of exposure in the treatment of mumps

Rice. 82. Projection of the parotid gland.

The duration of the course of therapy is up to 12 procedures with a mandatory repeated treatment course, performed after 3-5 weeks.

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B26 Mumps

Mumps or mumps is a mild viral disease that manifests itself as swelling of the salivary glands on one or both sides of the mandible.

Mostly unvaccinated schoolchildren and young people are ill. Genetics, gender, lifestyle do not matter. The mumps virus enters the saliva of sick people, so it can spread by airborne droplets through coughing and sneezing.

The virus causes swelling of one or both of the parotid glands, which are located below and in front of the ear canal. With the defeat of both glands, the child takes on the characteristic appearance of a hamster. In adolescent boys and young men (about 1 in 4), this virus can cause painful inflammation of one or both testicles, and in rare cases, infertility can be the result.

About half of all infected people have mumps without symptoms, and most of the rest have mild symptoms. The main symptoms of mumps appear 2-3 weeks after infection and are as follows:

• soreness and swelling on one or both sides of the face, under and in front of the ears, for at least 3 days;
• pain when swallowing.

The child may develop sore throat and fever, and the salivary glands under the jaw become painful. Sick mumps becomes contagious as early as 7 days before the onset of symptoms and remains so for 10 days after the symptoms disappear.

The doctor diagnoses the disease by the characteristic swelling of the parotid salivary glands. There is no specific treatment, but drinking plenty of cool fluids and taking over-the-counter pain relievers such as acetaminophen is essential to relieve discomfort.

Most people who get sick recover without treatment, although strong analgesics are prescribed for adolescents and young men with severe inflammation of the testicles. If complications develop, special treatment is recommended.

Young children are immunized immediately against measles, mumps and rubella, the first time at 12-15 months, and then at 4-6 years.

Complete medical reference / Per. from English E. Makhiyanova and I. Dreval. - M .: AST, Astrel, 2006.

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Synonyms - mumps infection, parotitis epidemica, mumps, mumps, trench disease, soldier's disease.

Mumps is an acute anthroponous airborne infectious disease characterized by a predominant lesion of the salivary glands and other glandular organs (pancreas, gonads, more often the testicles, etc.), as well as the central nervous system.

B26. Parotitis.

B26.0 †. Mumps orchitis.

B26.1 †. Mumps meningitis.

B26.2 †. Mumps encephalitis.

B26.3 †. Mumps pancreatitis.

B26.8. Mumps with other complications.

B26.9. Epidemic mumps, uncomplicated.

Causes and etiology of mumps

The causative agent of mumps- Pneumophila parotiditis virus, pathogenic for humans and monkeys. It belongs to paramyxoviruses (family Paramyxoviridae, genus Rubulavirus), antigenically close to the parainfluenza virus. The genome of the mumps virus is represented by a single-stranded helical RNA surrounded by a nucleocapsid. The virus is characterized by pronounced polymorphism: it is round, spherical or irregular in shape, and its size can vary from 100 to 600 nm. Has hemolytic, neuraminidase and hemagglutinating activity associated with glycoproteins HN and F. ultraviolet irradiation, drying, quickly collapses in disinfectant solutions (50% ethyl alcohol, 0.1% formalin solution, etc.). At low temperatures (–20 ° C), it can persist in the environment for up to several weeks. The antigenic structure of the virus is stable.

Only one serotype of the virus is known, which has two antigens: V (viral) and S (soluble). The optimum pH of the medium for the virus is 6.5-7.0. Of the laboratory animals, monkeys are the most sensitive to the mumps virus, in which it is possible to reproduce the disease by introducing a virus-containing material into the duct of the salivary gland.

Epidemiology of mumps

Mumps is traditionally considered a childhood infection. At the same time, mumps in infants and under 2 years of age is rare. From 2 to 25 years old, the disease is very common, it becomes rare again after 40 years. Many doctors refer to mumps as a disease of school age and conscription. The incidence rate in US troops during World War II was 49.1 per 1,000 troops.

In recent years, mumps in adults has been more common due to the mass vaccination of children. In most of the vaccinated, the concentration of protective antibodies is significantly reduced after 5–7 years. This contributes to an increased susceptibility to the disease in adolescents and adults.

Source of the causative agent of the disease- a person with mumps who begins to excrete the virus 1-2 days before the onset of the first clinical symptoms and before the 9th day of illness. Moreover, the most active release of the virus into the environment occurs in the first 3-5 days of the disease.

The virus is excreted from the patient's body with saliva and urine. It has been established that the virus can be found in other biological fluids of the patient: blood, breast milk, cerebrospinal fluid and in the affected glandular tissue.

The virus is transmitted by airborne droplets. The intensity of the release of the virus into the environment is low due to the absence of catarrhal phenomena. One of the factors that accelerates the spread of the mumps virus is the presence of concomitant acute respiratory infections, in which, due to coughing and sneezing, the release of the pathogen into the environment increases. The possibility of infection through household items (toys, towels) infected with the patient's saliva is not excluded.

The vertical route of transmission of mumps from a sick pregnant woman to a fetus is described. After the disappearance of the symptoms of the disease, the patient is not contagious.

The susceptibility to infection is high (up to 100%). The "sluggish" mechanism of transmission of the pathogen, long incubation, a large number of patients with erased forms of the disease, which makes it difficult to identify and isolate, leads to the fact that outbreaks of mumps in children and adolescent groups proceed for a long time, in waves for several months. Boys and adult men suffer from this disease 1.5 times more often than women. Seasonality is characteristic: the maximum incidence occurs in March-April, the minimum - in August-September. Among the adult population, epidemic outbreaks are recorded more often in closed and semi-closed collectives - barracks, hostels, ship crews. Rise in incidence is noted with a frequency of 7–8 years.

Mumps is classified as a preventable infection. After the introduction of immunization into practice, the incidence has decreased significantly, but only 42% of countries in the world include mumps vaccination in the national vaccination schedules. Due to the constant circulation of the virus, anti-parotitis antibodies are found in 80–90% of people over 15 years of age. This indicates the widespread occurrence of this infection, and it is believed that in 25% of cases of mumps occurs inapparently.

After a previous illness, patients develop a stable lifelong immunity, repeated diseases are extremely rare.

The pathogenesis of mumps

The mumps virus enters the body through the mucous membrane of the upper respiratory tract and the conjunctiva. It has been shown experimentally that the application of the virus to the mucous membrane of the nose or cheek leads to the development of the disease. After entering the body, the virus multiplies in the epithelial cells of the respiratory tract and spreads with the blood stream to all organs, of which the salivary, genital and pancreas, as well as the central nervous system, are most sensitive to it. Early viremia and damage to various organs and systems that are distant from each other testify to the hematogenous spread of infection.

The viremia phase does not exceed five days. Damage to the central nervous system and other glandular organs can occur not only after, but also simultaneously, earlier and even without damage to the salivary glands (the latter is very rarely observed). The nature of morphological changes in the affected organs has not been studied enough. It was found that connective tissue damage prevails, not glandular cells. At the same time, for the acute period, the development of edema and lymphocytic infiltration of the interstitial space of the glandular tissue is typical, however, the mumps virus can simultaneously infect the glandular tissue itself. A number of studies have shown that with orchitis, in addition to edema, the parenchyma of the testicles is also affected. This leads to a decrease in the production of androgens and leads to a violation of spermatogenesis. A similar nature of the lesion has been described for lesions of the pancreas, which may result in atrophy of the islet apparatus with the development of diabetes mellitus.

Symptoms and clinical picture of mumps

There is no generally accepted classification of mumps. This is explained by the different interpretation of the manifestations of the disease by specialists. A number of authors consider that the characteristic manifestation of the disease is only the defeat of the salivary glands, and the damage to the nervous system and other glandular organs - as complications or manifestations of an atypical course of the disease.

The position is pathogenetically substantiated according to which the lesions not only of the salivary glands, but also of other localization caused by the mumps virus, should be considered precisely as manifestations, and not complications of the disease. Moreover, they can manifest in isolation without affecting the salivary glands. At the same time, lesions of various organs as isolated manifestations of mumps infection are rarely observed (atypical form of the disease).

On the other hand, the erased form of the disease, which was diagnosed before the start of routine vaccination during almost every outbreak of the disease in children and adolescents and during routine examinations, cannot be considered atypical. Asymptomatic infection is not considered a disease. The classification should also reflect the frequent adverse long-term consequences of mumps. The severity criteria are not included in this table, since they are completely different for different forms of the disease and do not have nosological specificity. Complications are rare and do not have specific features, therefore they are not considered in the classification. The clinical classification of mumps includes the following clinical forms.

With isolated lesions of the salivary glands:

- with damage to the salivary glands and other glandular organs;

- with damage to the salivary glands and the nervous system.

Atypical (without damage to the salivary glands).

With the defeat of the glandular organs.

With damage to the nervous system.

Recovery with residual pathology:

The incubation period is 11 to 23 days (usually 18–20). Often the expanded picture of the disease is preceded by a prodromal period.

In some patients (more often in adults), 1-2 days before the development of a typical picture, prodromal phenomena are observed in the form of weakness, malaise, hyperemia of the oropharynx, muscle pain, headache, sleep disturbances and appetite.

Typically acute onset, chills and fever up to 39–40 ° C.

One of the early signs of the disease is soreness behind the earlobe (Filatov's symptom).

Swelling of the parotid gland often appears by the end of the day or on the second day of the disease, first on one side, and after 1-2 days in 80-90% of patients - on the other. In this case, tinnitus is usually noted, pain in the ear area, aggravated by chewing and talking, trismus is possible. The enlargement of the parotid gland is clearly visible. The gland fills the fossa between the mastoid bone and the mandible. With a significant increase in the parotid gland, the auricle protrudes and the earlobe rises upward (hence the popular name "mumps"). The edema spreads in three directions: anteriorly to the cheek, downward and posteriorly to the neck, and upward to the area of ​​the mastoid process. Puffiness is especially noticeable when examining the patient from the back of the head. The skin over the affected gland is tense, of normal color, on palpation the gland has a test consistency, moderately painful. The maximum degree of edema reaches on the 3-5th day of the disease, then gradually decreases and disappears, as a rule, on the 6-9th day (in adults, on the 10-16th day). During this period, salivation is reduced, the oral mucosa is dry, patients complain of thirst. The stenon's duct is clearly visible on the buccal mucosa in the form of a hyperemic edematous ringlet (Mursu's symptom). In most cases, the process involves not only the parotid, but also the submandibular salivary glands, which are defined as slightly painful spindle-shaped swellings of a test consistency; in case of damage to the hyoid gland, swelling is noted in the chin region and under the tongue. The defeat of only the submandibular (submaxillitis) or sublingual glands is extremely rare. Internal organs with isolated mumps, as a rule, are not changed. In some cases, patients have tachycardia, a murmur at the apex and muffling of heart sounds, hypotension.

Symptoms of mumps in children and adults

The defeat of the central nervous system is manifested by headache, insomnia, adynamia. The total duration of the febrile period is usually 3-4 days, in severe cases - up to 6-9 days.

A common symptom of mumps in adolescents and adults is testicular damage (orchitis). The frequency of mumps orchitis directly depends on the severity of the disease. In severe and moderate forms, it occurs in about 50% of cases. Orchitis is possible without affecting the salivary glands. Signs of orchitis are noted on the 5-8th day of illness against the background of a decrease and normalization of temperature.

In this case, the condition of the patients deteriorates again: the body temperature rises to 38–39 ° C, chills, headache appear, nausea and vomiting are possible. There is severe pain in the scrotum and testicles, sometimes radiating to the lower abdomen. The testicle increases 2-3 times (up to the size of a goose egg), becomes painful and dense, the skin of the scrotum is hyperemic, often with a bluish tinge. One testicle is most often affected. Severe clinical manifestations of orchitis persist for 5-7 days. Then the pain disappears, the testicle gradually decreases in size. In the future, signs of his atrophy can be noted.

In almost 20% of patients, orchitis is combined with epididymitis. The epididymis is palpable as an oblong painful swelling. This condition leads to impaired spermatogenesis. Data have been obtained on the erased form of orchitis, which can also be the cause of male infertility. With mumps orchitis, pulmonary infarction due to thrombosis of the veins of the prostate and pelvic organs has been described. An even rarer complication of mumps orchitis is priapism. Women may develop oophoritis, bartholinitis, mastitis. Uncommon in female patients in the post-pubertal period, oophoritis, which does not affect fertility and does not lead to sterility. It should be noted that mastitis can also develop in men.

A frequent manifestation of mumps is acute pancreatitis, often asymptomatic and diagnosed only on the basis of an increase in the activity of amylase and diastase in the blood and urine. The incidence of pancreatitis, according to various authors, varies widely - from 2 to 50%. More often it develops in children and adolescents. This scatter of data is associated with the use of various criteria for the diagnosis of pancreatitis. Pancreatitis usually develops on the 4-7th day of illness. Nausea, repeated vomiting, diarrhea, pain of a girdle nature in the middle part of the abdomen are observed. With severe pain syndrome, tension of the abdominal muscles and symptoms of peritoneal irritation are sometimes noted. Characterized by a significant increase in amylase (diastase) activity, which lasts up to one month, while other symptoms of the disease disappear after 5-10 days. Damage to the pancreas can lead to atrophy of the islet apparatus and the development of diabetes.

In rare cases, damage to other glandular organs is possible, usually in combination with the salivary glands. Thyroiditis, parathyroiditis, dacryoadenitis, thymoiditis are described.

Damage to the nervous system is one of the most frequent and significant manifestations of mumps infection. Serous meningitis is most often observed. Meningoencephalitis, neuritis of the cranial nerves, polyradiculoneuritis are also possible.

The clinical picture of mumps meningitis is polymorphic, therefore, the diagnostic criterion can only be the identification of inflammatory changes in the CSF.

Cases of mumps are possible, occurring with meningism syndrome, with intact CSF. On the contrary, often without the presence of meningeal symptoms, inflammatory changes in the CSF are noted; therefore, the data on the frequency of meningitis, according to various authors, vary from 2–3 to 30%. Meanwhile, timely diagnosis and treatment of meningitis and other lesions of the central nervous system significantly affects the long-term consequences of the disease.

Meningitis is more common in children aged 3–10 years. In most cases, it develops on the 4-9th day of illness, ie. in the midst of the defeat of the salivary glands or against the background of the subsiding of the disease. However, it is possible that symptoms of meningitis appear simultaneously with damage to the salivary glands and even earlier.

Cases of meningitis without affecting the salivary glands are possible, in rare cases - in combination with pancreatitis. The onset of meningitis is characterized by a rapid increase in body temperature to 38–39.5 ° C, accompanied by intense headache of a diffuse nature, nausea and frequent vomiting, and skin hyperesthesia. Children become lethargic, adynamic. Already in the first day of the disease, meningeal symptoms are noted, which are moderately expressed, often not in full, for example, only the symptom of landing ("tripod").

Young children may experience convulsions, loss of consciousness, and older children may experience psychomotor agitation, delirium, and hallucinations. General cerebral symptoms usually regress within 1–2 days. Preservation for a longer time indicates the development of encephalitis. An essential role in the development of meningeal and general cerebral symptoms is played by intracranial hypertension with an increase in LD up to 300–600 mm of water column. Careful dropwise evacuation of CSF during lumbar puncture to the normal level of LD (200 mm water column) is accompanied by a pronounced improvement in the patient's condition (cessation of vomiting, clarification of consciousness, decrease in the intensity of headache).

CSF with mumps meningitis is transparent or opalescent, pleocytosis is 200–400 in 1 μl. The protein content is increased to 0.3–0.6 / l, sometimes up to 1.0–1.5 / l; a reduced or normal protein level is rarely observed. Cytosis, as a rule, is lymphocytic (90% and more), in 1-2 days of the disease it can be mixed. The concentration of glucose in the blood plasma is within the normal range or increased. Rehabilitation of cerebrospinal fluid occurs later than regression of the meningeal syndrome, by the 3rd week of the disease, but it can be delayed, especially in older children, up to 1–1.5 months.

With meningoencephalitis, 2–4 days after the development of a picture of meningitis, against the background of a weakening of meningeal symptoms, cerebral symptoms increase, focal symptoms appear: flattening of the nasolabial fold, deviation of the tongue, revitalization of tendon reflexes, anisoreflexia, muscular hypertonicity, pyramidal signs, symptoms of oral feet ataxia, intentional tremor, nystagmus, transient hemiparesis. In young children, cerebellar disorders are possible. Mumps meningitis and meningoencephalitis are benign. As a rule, complete restoration of central nervous system functions occurs, but sometimes intracranial hypertension, asthenization, loss of memory, attention, hearing can persist.

Against the background of meningitis, meningoencephalitis, sometimes in isolation, neuritis of the cranial nerves, most often of the VIII pair, may develop. At the same time, dizziness, vomiting are noted, aggravated by a change in body position, nystagmus.

Patients try to lie still with their eyes closed. These symptoms are associated with damage to the vestibular apparatus, but cochlear neuritis is also possible, which is characterized by the appearance of noise in the ear, hearing loss, mainly in the high-frequency zone. The process is usually one-sided, but often the hearing does not completely recover. It should be borne in mind that with pronounced parotitis, a short-term hearing loss is possible due to edema of the external auditory canal.

Polyradiculoneuritis develops against the background of meningitis or meningoencephalitis, it is always preceded by the defeat of the salivary glands. In this case, the appearance of radicular pain and symmetrical paresis of predominantly distal extremities is characteristic, the process is usually reversible, and the respiratory muscles may also be damaged.

Sometimes, usually on the 10-14th day of the disease, more often in men, polyarthritis develops. Large joints (shoulder, knee) are mainly affected. The process, as a rule, is reversible, ends with complete recovery within 1-2 weeks.

Complications (tonsillitis, otitis media, laryngitis, nephritis, myocarditis) are extremely rare. Changes in the blood during mumps are insignificant and are characterized by leukopenia, relative lymphocytosis, monocytosis, increased ESR; in adults, leukocytosis is sometimes noted.

Diagnosis of mumps

Diagnosis is based mainly on the characteristic clinical picture and epidemiological history, and in typical cases does not cause difficulties. Of the laboratory methods for confirming the diagnosis, the most convincing is the isolation of the mumps virus from the blood, the secretion of the parotid gland, urine, CSF and pharyngeal lavages, but in practice this is not used.

In recent years, serological diagnostic methods have begun to be used more often, the most often used are ELISA, RSK and RTGA. A high IgM titer and a low IgG titer in the acute period of infection can be a sign of mumps. The diagnosis can be finally confirmed in 3-4 weeks by re-examining the antibody titer, while an increase in the IgG titer by 4 times or more has a diagnostic value. When using RSK and RTGA, cross-reactions with the parainfluenza virus are possible.

Recently, diagnostic methods have been developed using PCR of the mumps virus. For diagnosis, the activity of amylase and diastase in blood and urine is often determined, the content of which increases in most patients. This is especially important not only for the diagnosis of pancreatitis, but also for indirect confirmation of the mumps etiology of serous meningitis.

Differential diagnosis

Differential diagnosis of mumps should primarily be carried out with bacterial parotitis, salivary stone disease. An enlarged salivary gland is also seen in sarcoidosis and tumors. Mumps meningitis is differentiated from serous meningitis of enteroviral etiology, lymphocytic choriomeningitis, and sometimes tuberculous meningitis. In this case, an increase in the activity of pancreatic enzymes in the blood and urine with mumps meningitis is of particular importance.

The greatest danger are cases when the edema of the subcutaneous tissue of the neck and lymphadenitis, which occurs in toxic forms of diphtheria of the oropharynx (sometimes with infectious mononucleosis and herpesvirus infections), is mistaken by the doctor for mumps. Acute pancreatitis should be differentiated from acute surgical diseases of the abdominal cavity (appendicitis, acute cholecystitis).

Mumps orchitis is differentiated from tuberculous, gonorrheal, traumatic and brucellosis orchitis.

Algorithm for the diagnosis of mumps infection in adults.

Symptoms of intoxication - Yes - Pain when chewing and opening the mouth in the area of ​​the salivary glands - Yes - Increase in one or more salivary glands (parotid, submandibular) - Yes - Simultaneous damage to the salivary glands and pancreas, testicles, mammary glands, development of serous meningitis - Yes - Study completed, diagnosis: mumps

Table Differential diagnosis of mumps

Indications for consulting other specialists

In the presence of neurological symptoms, consultation with a neurologist is indicated, with the development of pancreatitis (abdominal pain, vomiting) - with a surgeon, with the development of orchitis - with a urologist.

An example of a diagnosis formulation

B26, B26.3. Mumps, pancreatitis, moderate course of the disease.

Treatment of mumps

Patients from closed children's groups (orphanages, boarding schools, military units) are hospitalized. As a rule, patients are treated at home. Hospitalization is indicated for severe disease (hyperthermia over 39.5 ° C, signs of central nervous system damage, pancreatitis, orchitis). In order to reduce the risk of complications, regardless of the severity of the course of the disease, patients should be kept in bed during the entire period of fever. It was shown that in men who did not comply with bed rest in the first 10 days of illness, orchitis developed 3 times more often.

In the acute period of the disease (up to 3-4 days of illness), patients should receive only liquid and semi-liquid food. Given the disturbances in salivation, great attention should be paid to the care of the oral cavity, and during the recovery period it is necessary to stimulate the secretion of saliva, using, in particular, lemon juice.

For the prevention of pancreatitis, a dairy-vegetable diet is advisable (table number 5). Shown a plentiful drink (fruit drinks, juices, tea, mineral water).

For headaches, metamizole sodium, acetylsalicylic acid, paracetamol are prescribed. It is advisable to prescribe desensitizing drugs.

To reduce the local manifestations of the disease, light and heat therapy (sollux lamp) is prescribed to the area of ​​the salivary glands.

For orchitis, prednisone is used for 3-4 days at a dose of 2-3 mg / kg per day, followed by a dose reduction of 5 mg daily. It is obligatory to wear the suspensor for 2-3 weeks to ensure the elevated position of the testicles.

In acute pancreatitis, a sparing diet is prescribed (on the first day - a starvation diet). Shown cold on the stomach. To reduce pain, analgesics are administered, aprotinin is used.

If meningitis is suspected, a lumbar puncture is indicated, which has not only diagnostic, but also therapeutic value. At the same time, analgesics are also prescribed, dehydration therapy using furosemide (lasix) at a dose of 1 mg / kg per day, acetazolamide.

With severe cerebral syndrome, dexamethasone is prescribed at 0.25-0.5 mg / kg per day for 3-4 days with meningoencephalitis - nootropic drugs in courses of 2-3 weeks.

Forecast

Favorable, lethal outcomes are rare (1 per 100 thousand people with mumps). Some patients may develop epilepsy, deafness, diabetes mellitus, decreased potency, testicular atrophy, followed by the development of azospermia.

Approximate terms of incapacity for work

The terms of disability are determined depending on the clinical course of mumps, the presence of meningitis and meningoencephalitis, pancreatitis, orchitis and other specific lesions.

Clinical examination

Not regulated. It is carried out by an infectious disease doctor, depending on the clinical picture and the presence of complications. If necessary, specialists from other specialties (endocrinologists, neurologists, etc.) are involved.

Prevention of mumps

Patients with mumps are isolated from children's groups for 9 days. Contact persons (children under 10 years of age, who have not had mumps and who have not been vaccinated) are subject to separation for a period of 21 days, and in cases of exact date of contact - from the 11th to the 21st day. Carry out wet cleaning of the room using disinfectants and airing the room. For children who have had contact with the patient, during the period of isolation, medical supervision is established. The basis of prevention is vaccination within the framework of the national calendar of preventive vaccinations in Russia.

Vaccination is carried out with a mumps cultural live dry vaccine of domestic production, taking into account contraindications at 12 months and revaccination at 6 years. The vaccine is injected subcutaneously in a volume of 0.5 ml under the scapula or into the outer surface of the shoulder. After the introduction of the vaccine, a short fever, catarrhal phenomena for 4-12 days are possible, very rarely - an increase in the salivary glands and serous meningitis. For emergency prophylaxis, the vaccine is administered to those who are not vaccinated against mumps and who are not ill no later than 72 hours after contact with the patient. Also certified are the measles-measles cultural live dry vaccine (manufactured in Russia) and the live attenuated lyophilized vaccine against measles, mumps and rubella (manufactured in India).

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Parotid infection (code according to ICD-10 - B26

Mumps infection (mumps, mumps) is an acute viral disease with a predominant lesion of the salivary glands; less often other glandular organs are affected: pancreas, testes, ovaries, mammary glands, etc., as well as the nervous system (serous meningitis, meningoencephalitis, neuritis, etc.).

For 1-2 days, the iron from the opposite side is involved in it. The skin over the swelling is tense, but no inflammatory changes. On palpation, the salivary gland is soft or doughy, painful. Allocate painful points N.F. Filatova: in front of the earlobe, in the region of the apex of the mastoid process and in the place of the notch of the lower jaw.

The defeat of the submandibular salivary glands (submaxillitis) is often combined with the defeat of the parotid salivary glands, rarely the primary and only manifestation of the disease. In these cases, the swelling is located in the submandibular region in the form of a round formation of a pasty consistency. In severe forms in the area of ​​the gland, edema of the tissue may appear, spreading to the neck.

An isolated lesion of the sublingual salivary gland - sublingualis - is extremely rare. In this case, the swelling appears under the tongue.

Orchitis usually appears 1-2 weeks after the onset of damage to the salivary glands; the primary localization of mumps infection, the testicles become less common. The disease is manifested by pain in the scrotum and testicle. The testicle enlarges, hardens, with

Rice. 2. Damage to the left parotid gland

palpation is sharply painful. The skin of the scrotum is slightly hyperemic.

Damage to the nervous system in mumps manifests itself as serous meningitis, meningoencephalitis, rarely neuritis or polyradiculoneuritis.

Serous meningitis often appears on the 7-10th day of illness, after the symptoms of damage to the salivary glands begin to subside or are almost completely eliminated. It begins acutely, with a rise in temperature, the appearance of a headache and repeated vomiting. From the first days of the disease, meningeal syndrome is revealed: stiff neck muscles, positive symptoms of Kernig, Brudzinsky. The severity of clinical manifestations can be different, which determines the severity of the disease. The final diagnosis is based on the results of a lumbar puncture. With mumps meningitis, the cerebrospinal fluid is transparent, flows out in frequent drops or a stream, high lymphocytic cytosis is detected (from 0.5x106 / l to 3x106 / l), up to 95-98% of lymphocytes. The protein content is slightly increased (from 0.99 to 1.98 g / l), and the amount of glucose and chlorides is within the normal range.

When serous meningitis is combined with encephalitis (meningoencephalitis), the disease is manifested by impaired consciousness, delirium, convulsions, hyperkinesis and pathological reflexes are possible.

Neuritis and polyradiculoneuritis are rare. A sudden enlargement of the parotid gland can lead to compression of the facial nerve and paralysis. In this case, on the side of the affected facial nerve, the function of the facial muscles is disturbed: the folds of the forehead are smoothed, the eyebrow is somewhat pubescent, the eyelid does not close (hare's eye), the nasolabial fold is smoothed. Soreness appears at the exit point of the facial nerve.

In the period of mumps convalescence, polyradiculitis of the Guillain-Barre type is possible. Clinically, they are manifested by gait disturbance, paresis and paralysis of the lower extremities, which have all the peripheral signs: absence of reflexes, decreased muscle tone, muscle atrophy, symmetry of the lesion. At the same time, pain occurs. In the cerebrospinal fluid, the protein content rises and lymphocytic cytosis increases.

Mumps pancreatitis usually develops in combination with damage to other organs and systems, occurs on the 5-9th day from the onset of the disease. In rare cases, it is the only manifestation of the disease. The diagnosis is made by an increase in the level of amylase in the blood.

For laboratory confirmation by ELISA, specific IgM class antibodies are detected in the blood. Specific class IgC antibodies appear somewhat later and persist for many years.

Mumps infection, which occurs with damage to the salivary glands, is differentiated from purulent mumps, mumps with sepsis, infectious mononucleo

zom, with blockage of the duct of the salivary gland, etc. Mumps meningitis is differentiated from enterovirus serous meningitis, tuberculous meningitis. Mumps orchitis is differentiated from enterovirus orchitis, bacterial orchitis, etc.

Purulent mumps usually occurs against the background of any bacterial infection of the oral cavity, paranasal sinuses, sepsis.

With infectious mononucleosis, the lymph nodes, including the parotid ones, are enlarged. The salivary glands remain unaffected.

When the salivary gland duct is blocked, the process is one-sided, there is no fever. Salivary gland stones can be detected with sialography or ultrasound.

Serous meningitis of enteroviral etiology is rarely the only manifestation of the disease. The data of the epidemic history and the results of laboratory examination are of decisive importance.

Tuberculous meningitis is characterized by a gradual onset of the disease, a slow increase in meningeal symptoms, and the loss of a fibrinous film in the form of a cobweb in a test tube with cerebrospinal fluid. The disease usually develops against the background of active respiratory tuberculosis.

There is no specific treatment.

When clinical symptoms of pancreatitis appear, the patient needs bed rest and a more strict diet. In severe cases, they resort to intravenous drip of liquid with proteolysis inhibitors - aprotinin (gordox, contrikal, trasilol). To relieve pain, antispasmodics and analgesics are prescribed: metamizole sodium (analgin), papaverine, drotaverin (no-shpu). For better

Rice. 3. Submaxillitis

For digestion, it is recommended to prescribe enzyme preparations (pancreatin, panzinorm, festal). To prevent the development of complications in patients with severe forms of the disease, inducers of interferonogenesis (viferon, cycloferon, anaferon for children, etc.) are recommended.

It is better to hospitalize a patient with orchitis. Prescribe bed rest, support for the acute period of the disease. Corticosteroid hormones are used as anti-inflammatory drugs based on

2-3 mg / kg per day (for prednisone) in 3-4 doses for 3-4 days, followed by a rapid dose reduction with a total course duration of no more than 7-10 days. To relieve pain, analgesics and desensitizing drugs are prescribed: chloropyramine (suprastin), promethazine (pipolfen), hifenadine (fenkarol). With significant testicular edema in order to eliminate

of pressure on the parenchyma of the organ is justified by surgical intervention - dissection of the tunica albuginea.

If mumps meningitis is suspected, a spinal tap is indicated for diagnostic purposes; in rare cases, it can also be performed as a therapeutic measure to lower intracranial pressure. For the purpose of dehydration, lasix is ​​administered. In severe cases, they resort to infusion therapy (1.5% Reamberin solution, 20% glucose solution, B vitamins).

Patients with mumps infection are isolated from the children's team until the clinical manifestations disappear (no more than 9 days). Among the contact persons, children under 10 years of age who have not had mumps infection and have not received active immunization are subject to separation for a period of 21 days. In cases of exact establishment of the date of contact, the time of separation is reduced and children are subject to isolation from the 11th to the 21st day of the incubation period. Final disinfection at the site of infection is not carried out, but the room should be ventilated and wet cleaned using disinfectants.

The only reliable method of prevention is active immunization.

For vaccination, use domestic mumps cultural live vaccine, as well as live attenuated mumps-measles divaccine. The vaccine strain of the domestic vaccine is grown on the cell culture of Japanese quail embryos. The following combined vaccines for the prevention of measles and rubella and mumps are also permitted in Russia: Priorix (GlaxoSmithKline, England), MM R-11 (Merck Sharp and Dome, USA), vaccine against measles, mumps, rubella of Indian production ( Serum Institute "). Foreign vaccine strains are cultivated on chicken embryos.

Children under the age of 12 months with revaccination at 6 years old who have not had mumps infection are subject to vaccination. The vaccine is injected subcutaneously in a volume of 0.5 ml into the outer surface of the shoulder. After the vaccination and revaccination, a strong (possibly lifelong) immunity is formed. It is also recommended to conduct vaccination according to epidemiological indications for adolescents and adults who are seronegative for epi demiologic and companions.

The vaccine is little reactogenic. Contraindications to vaccination are immunodeficiency states, severe forms of allergic reactions to egg white, aminoglycosides.

RCHD (Republican Center for Healthcare Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2016

Mumps (B26)

Short description

Approved
Joint Commission on the Quality of Medical Services
Ministry of Health and Social Development of the Republic of Kazakhstan
dated August 16, 2016
Protocol No. 9

Mumps infection. Epidemic parotitis (parotitis epidemica) is an acute viral disease caused by a paramyxovirus, characterized by fever, general intoxication, enlargement of one or more salivary glands, and often damage to other glandular organs and the central nervous system.

The ratio of the codes ICD-10 and ICD-9

ICD-10		ICD-9
Code	Name	Code	Name
T 26	Parotitis	-	-
H 26.0	Mumps orchitis
H 26.1	Mumps meningitis
H 26.2	Mumps encephalitis
H 26.3	Mumps pancreatitis
H 26.8	Mumps with other complications
At 26.9	Mumps without complications

Date of protocol development: 2016 year.

Protocol users: emergency doctors, paramedics, general practitioners, therapists, infectious disease specialists.

Evidence level scale:

A	High quality meta-analysis, systematic review of RCTs, or large RCTs with very low probability (++) bias, the results of which can be generalized to the relevant population.
V	High-quality (++) systematic review of cohort or case-control studies or High-quality (++) cohort or case-control studies with very low risk of bias or RCTs with low (+) risk of bias that can be generalized to the relevant population ...
WITH	A cohort or case-control study or controlled study without randomization with a low risk of bias (+). The results of which can be generalized to the relevant population or RCTs with very low or low risk of bias (++ or +), the results of which cannot be directly extended to the relevant population.
D	Description of a series of cases or uncontrolled research or expert opinion.

Classification

Clinical classification of mumps (Lobzin Yu.V., 2003).

Type:
A. Typical forms:
· Uncomplicated: damage to only the salivary glands, one or more;
· Complicated: damage to the salivary glands and other organs (meningitis, meningoencephalitis, pancreatitis, orchitis, mastitis, myocarditis, arthritis, nephritis).

By severity:
· light;
· average;
· heavy.

B. Atypical forms:
· Erased;
· Inapparent.

B. Residual phenomena of mumps:
Testicular atrophy;
· Infertility;
· diabetes;
Deafness;
· Dysfunction of the central nervous system.

Diagnostics (outpatient clinic)

DIAGNOSTICS AT THE AMBULATORY LEVEL

Diagnostic criteria:
Complaints:
Body temperature up to 38.0-40.0 ° С;
· headache;
Chills;
• sleep and appetite disturbance;
• weakness, malaise;

· Pain in the ear;
Dry mouth.

Anamnesis:
· Acute onset of the disease;

· Contact with the patient;

Physical examination
Typical syndromes:
Intoxication syndrome:
· An increase in temperature from subfebrile numbers (with mild severity) to 38.0-40.0 ° C (with moderate and severe severity). Fever reaches its maximum severity on the 1-2 day of illness and lasts 4-7 days, the temperature decrease occurs lytically. With a complicated course of mumps, intoxication and fever proceed in waves, each wave is associated with the appearance of another complication.

Mumps (



The skin over the swelling is stretched, it is difficult to fold, has
normal color, local temperature unchanged;
Positive symptom of Filatov (swelling and soreness when pressing on the tragus, mastoid process and in the region of the retromandibular fossa),

· Decrease in salivation.

· Decrease in salivation.

Sublingual:

· Decrease in salivation;

Complications:


· nausea, vomiting;

Loose stools or constipation.

Orchitis (damage to the gonads):
· Increased body temperature;


· Dense consistency;

· The skin of the scrotum is hyperemic;


· "Autonomous" orchitis (the only "manifestation of the disease.

Prostatitis (damage to the prostate gland):

):
· Increased body temperature;
• weakness, malaise;

Serous meningitis:
Serous meningitis is combined with damage to other organs and systems, begins 3-6 days after the onset of symptoms of mumps:
· Acute onset;

· headache;
· Repeated vomiting;
· insomnia;
Hyperesthesia;
• photophobia;
Hyperacusis;
· Convulsions;
• delirium;

In rare cases, symptoms of serous meningitis precede the damage to the salivary glands.

Meningoencephalitis develops on the 6-10th day of the disease, a rare, severe complication of mumps:
· Strong headache;
· Repeated vomiting;
Weakness;
Drowsiness;
· Lethargy;
· loss of consciousness;

· Paresis of the cranial nerves;
· Hemiparesis;
Cerebellar ataxia.

Mononeurites (

Myelitis and encephalomyelitis

Severity criteria mumps:

Light form:
Symptoms of intoxication are absent or mild (increased body temperature to subfebrile numbers, slight weakness, malaise, headache);
· There are no complications.

Moderate form:


· The presence of complications.

Severe form:

· Multiple complications;

Laboratory research
Clinical analysis:

Biochemical analysis:
· Biochemical blood test: increased amylase activity;
· Biochemical analysis of urine: increased activity of diastase.

Serological blood test:
ELISA - detection of IgM to the mumps virus.

Instrumental research:
· Are not carried out at the outpatient level.

Diagnostic algorithm

Diagnostics (hospital)

DIAGNOSTICS AT STATIONARY LEVEL

Diagnostic criteria at the inpatient level
Complaints:
Body temperature up to 38.0-40.0 ° С;
· headache;
Chills;
• sleep and appetite disturbance;
• weakness, malaise;
Soreness when chewing and opening the mouth;
· Pain in the ear;
Dry mouth.

Anamnesis:
· Acute onset of the disease;
· The appearance of swelling in the parotid region on the one hand, after a few days on the other;
· Contact with the patient;
· Lack of vaccination and past mumps.

Physical examination
Intoxication syndrome:
· An increase in temperature from subfebrile numbers (with mild severity) to 38.0-40.0 ° C (with severe severity). Fever reaches its maximum severity on the 1-2nd day of illness and lasts 4-7 days, the temperature decrease occurs lytically. With a complicated course of mumps, intoxication and fever proceed in waves, each wave is associated with the appearance of another complication.

Syndrome of defeat of glandular organs
Mumps (unilateral lesion of the parotid salivary glands):
Moderately painful swelling in the parotid region in front, below and behind the auricle, doughy consistency, in the center of the seal, the earlobe is protruding, the inflamed gland fills the fossa between the neck and the lower jaw;
· With bilateral lesion of the glands, the head is "pear-shaped", the ears are protruding;
Swelling of the tissue around the gland spreading to the cheek, temporal region and mastoid (not always);
· The skin over the swelling is stretched, it is difficult to fold, has a normal color, the local temperature is not changed;
Positive Filatov symptom (swelling and soreness when pressing on the tragus, mastoid process and in the region of the retromandibular fossa;
A positive Murson symptom (when examining the mucous membrane of the cheeks, swelling and hyperemia around the mouth of the parotid (stenon) duct of the parotid gland);
· Decrease in salivation.

Submaxillitis (unilateral lesion of the submandibular salivary glands):
• under the lower jaw, a fusiform painful formation, doughy consistency, is palpated;
· Edema of soft tissues, extending to the neck (not always);
· Decrease in salivation.

Sublingual:
Swelling and soreness in the chin area and under the tongue;
· Decrease in salivation;
· Possible development of edema of the pharynx, larynx, tongue with a pronounced increase in the submandibular, sublingual salivary glands.

Pancreatitis (damage to the pancreas):
· Increased body temperature;
· nausea, vomiting;
· Pain in the upper abdomen;
Loose stools or constipation.

Orchitis (damage to the sex glands)
· Increased body temperature;
Pain in the affected testicle radiating to the groin and femoral region;
· Testicle enlargement by 2-3 times (more often unilateral lesion of the right testicle);
· "Primary" orchitis (preceded by an increase in the parotid salivary glands);
· "Concomitant" orchitis (develops simultaneously with mumps);
· "Autonomous" orchitis (the only manifestation of the disease);
· Dense consistency;
· Pain on palpation;
· Hyperemia of the skin of the scrotum.

Prostatitis (damage to the prostate gland)
Pain in the perineum and anus;
· Enlargement of the prostate gland using a digital examination of the rectum.

Oophoritis (damage to the female reproductive glands)
· Increased body temperature;
• weakness, malaise;
· Pain in the iliac region.

Syndrome of lesion of the central and peripheral nervous system
Serous meningitis:
Serous meningitis is combined with damage to other organs and systems, begins 3-6 days after the onset of mumps symptoms.
· Acute onset;
· A sharp increase in body temperature up to 39.0-40.0 ° С;
· headache;
· Repeated vomiting;
· insomnia;
Hyperesthesia;
• photophobia;
Hyperacusis;
· Convulsions;
• delirium;
· loss of consciousness;
· Positive meningeal symptoms (stiff neck, symptoms of Brudzinski, Kernig).
In rare cases, symptoms of serous meningitis precede the damage to the salivary glands.

Meningoencephalitis develops on the 6-10th day of the disease, a rare, severe complication of mumps:
· Strong headache;
· Repeated vomiting;
Weakness;
Drowsiness;
· Lethargy;
· loss of consciousness;
· Clonic-tonic convulsions;
· Paresis of the cranial nerves;
· Hemiparesis;
Cerebellar ataxia.

Mononeurites ( lesion of the cranial nerves), mainly lesions of the VII pair of peripheral type and VIII pair:
With damage to the auditory nerve - dizziness, nystagmus, tinnitus, hearing loss.

Myelitis and encephalomyelitis appear on the 10-12th day of illness, are manifested by spastic lower paraparesis, dysfunction of the pelvic organs (stool and urinary incontinence).

Rare complications of mumps: mastitis, bartholinitis, thyroiditis, nephritis, urethritis, hemorrhagic cystitis, myocarditis, dacryocystitis, damage to the respiratory system, edema of the pharynx, larynx, tongue.

Severity criteria mumps:
· The severity of symptoms of intoxication;
· Presence or absence of complications.

Light form:
Symptoms of intoxication are absent or mild (increased body temperature to subfebrile numbers, slight weakness, malaise, headache), there are no complications.

Moderate form:
Febrile body temperature (38.0-39.0 ° C), symptoms of intoxication are expressed - general weakness, headache, chills, arthralgia, myalgia;
· A significant increase in the salivary glands;
· The presence of complications.

Severe form:
· Symptoms of severe intoxication: body temperature above 40 ° C, severe weakness, sleep disturbance, tachycardia, decreased blood pressure;
· Multiple complications;
· Toxicosis and fever proceed in the form of waves, each new wave is associated with the appearance of the next complication.

Laboratory research:
· KLA: leukopenia, lymphocytosis, ESR is not changed.
OAM: proteinuria, cylindruria (in severe disease).

CSF examination:
· Color - colorless;

· Pressure - the liquid flows out in a stream or in frequent drops, the pressure reaches 300-500 mm of water. Art .;

(according to indications):
Lumbar puncture - with the appearance of cerebral symptoms, positive meningeal symptoms;

· Ultrasound of the abdominal organs - to determine the degree of damage to the size and structure of the tissue of the pancreas;

Diagnostic algorithm: see ambulatory level.

List of main diagnostic measures:
UAC: leukopenia, lymphocytosis, ESR is not changed;
OAM: proteinuria, cylinduria (in severe disease);
· Biochemical blood test: increased activity of amylase, diastase.

Serological blood test:
ELISA - detection of Ig M to the mumps virus.
RSK, RTGA - an increase in antibody titer by 4 times or more in the study of paired sera (the first is taken at the onset of the disease, the second after 2-3 weeks), with a single study, the diagnostic titer is 1:80.

Molecular genetic method:
· PCR - detection of virus RNA in saliva, nasopharyngeal wash.

List of additional diagnostic measures:
CSF examination(according to indications):
· Color - colorless;
· Transparency - transparent or slightly opalescent;
· Pressure - the liquid flows out in a stream or in frequent drops, the pressure reaches 300-500 mm of water column;
· Pleocytosis - lymphocytic in the range of 300-700 cells, up to 1000 in 1 μl;
· An increase in protein to 0.3-0.9 g / l (with the development of meningoencephalitis, the indicators are higher);
· Glucose level is not changed, or slightly increased;
· The level of chlorides is not changed.

Instrumental research(according to indications):
Lumbar puncture - when detecting general cerebral symptoms, positive meningeal symptoms;
· Ultrasound of the salivary glands - to clarify the degree of damage;
· Ultrasound of the abdominal organs - to determine the degree of damage to the size and structure of the pancreas;
· Ultrasound of the organs of the scrotum, small pelvis - to determine the degree of damage to the organs of the reproductive system;
ECG - for violations of the cardiovascular system, for early detection of heart damage (with severe severity);
· X-ray of the chest organs - if there is a suspicion of the development of inflammatory changes in the lower parts of the respiratory system, including pneumonia;
EEG - in the presence of focal neurological symptoms, seizures, signs of intracranial hypertension.

Differential diagnosis

Diagnosis	Rationale for differential diagnosis	Surveys	Diagnosis exclusion criteria
Purulent parotitis	General symptoms: acute onset, severe symptoms of intoxication, fever, swelling in the parotid region.	Consultation with a surgeon	Fever above 39 ° C. The swelling in the area of ​​the salivary glands is sharply painful, dense with gradual softening and fluctuation. Defeat is always one-sided. Discharge of pus from the mouth of the stenonic duct. In the KLA, leukocytosis with a neutrophilic shift to the left, increased ESR.
Infectious mononucleosis	General symptoms: acute onset, fever, symptoms of intoxication, swelling in the parotid, submandibular regions.	Consultation with an infectious disease specialist	Enlargement of the cervical lymph nodes located in the form of chains along the sternocleidomastoid muscles, tonsillitis, hepatosplenomegaly, rash, possibly the presence of icteric syndrome. Persistent, prolonged fever. In the KLA, leukocytosis with a neutrophilic shift to the left, accelerated ESR. The diagnosis is confirmed when atypical mononuclear cells are detected in the blood and an increase in the titer of antibodies agglutinating foreign erythrocytes (Paul-Bunnel reaction).
Lymphogranulomatosis	Common symptoms: swelling in the parotid, submandibular regions.	Consultation with an infectious disease specialist, hematologist, oncologist	The defeat of the lymph nodes (all possible groups of l / nodes). In this case, the latter is usually preceded by "causeless" weakness, asthenization, periodic increase in body temperature, increased sweating. The disease is characterized by a long, progressive course. In the KLA, leukocytosis with a neutrophilic shift to the left, pronounced monocytosis, accelerated ESR. The final diagnosis of lymphogranulomatosis is confirmed by the results of a biopsy of the lymph node.
Salivary stone disease		Consultation with a surgeon	No fever and no intoxication. Recurrent course of the disease. The swelling increases and decreases, "salivary colic" increases with food intake. There is no damage to other organs. There are no changes in the UAC.
Mikulich's syndrome	Common symptoms: swelling in the parotid region	Consultation with a surgeon	The onset of the disease is gradual with the chronization of the process. Increased body temperature, no intoxication. The enlargement of the salivary glands is bilateral, lumpy, slightly painful. Damage to other organs: enlargement of the lymph glands, liver, spleen, ptosis. In the KLA, thrombocytopenia, anemia.

Algorithm for differential diagnostic search in the presence of swelling in the submandibular and parotid regions in the patient

Treatment abroad

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Treatment

Preparations (active ingredients) used in the treatment

Amoxicillin

Aprotinin

Ascorbic acid

Acetazolamide (Acetazolamide)

Dexamethasone

Dextrose

Diclofenac (Diclofenac)

Ibuprofen

Clavulanic acid

Loratadine

Mannitol (Mannitol)

Meglumine

Sodium chloride

Omeprazole (Omeprazole)

Pancreatin

Pantoprazole

Paracetamol (Paracetamol)

Prednisolone

Furosemide

Chloropyramine

Cetirizine

Cefazolin (Cefazolin)

Ceftriaxone

Treatment (outpatient clinic)

TREATMENT AT THE AMBULATORY LEVEL

On an outpatient basis, the treatment of mild and moderate forms of mumps without complications is carried out.

Drug-free treatment :

Drug treatment
Etiotropic therapy: not carried out.

Pathogenetic therapy
Detoxification therapy:
· Plentiful drink at the rate of 20-40 ml / kg.

Desensitizing therapy:


or
· Cetirizine 5 mg, 10 mg, 1 tablet by mouth 1 time per day, 5-7 days [LE-B],
or

Vitamin therapy

Symptomatic therapy:
With an increase in body temperature of more than 38.0 ° C
one of the following drugs:
· Ibuprofen 200 mg, 400 mg, 1 tablet by mouth 3-4 times a day, until the fever subsides [LE - A];
or

or

· Ascorbic acid, 50 mg, orally [UD - C].

· Ibuprofen 200 mg, 400 mg, by mouth [UD-A];
or
· Diclofenac 75 mg / 2 ml, IM [UD - A];
or
· Paracetamol 500 mg, by mouth [DD - A].
· Chloropyramine 25 mg, by mouth [UD - C];
or
· Cetirizine 5 mg, 10 mg, by mouth [LOA - B];
or
· Loratadine 10 mg, by mouth [LOA - B].

Indications for specialist consultation:
· Consultation with a surgeon: with the development of a clinic of acute abdomen and resolving the issue of surgical treatment of severe orchitis;



· Consultation of an obstetrician-gynecologist: in case of epidemic parotitis in pregnant women, in persons with lesions of the female genital glands.

Preventive actions:
Isolation until the 9th day from the moment of illness. There is no final disinfection in the outbreaks. The room is ventilated and wet cleaning is carried out using disinfectants.
Among the contact ones, children under 10 years old who have not suffered from epidemic parotitis and have not been vaccinated are subject to separation for a period of 21 days. From the 10th day of contact, systematic medical supervision is carried out (examination, thermometry).

In the foci of mumps, the circle of persons to be immunized for epidemic indications is determined. Immunization applies to persons who have had contact with the patient (if the disease is suspected), have not had mumps before, not vaccinated (or once vaccinated), with an unknown infectious and vaccine history, as well as persons who, during serological examination, did not reveal antibodies in protective titers to the mumps virus. According to epidemic indications, immunization against mumps is carried out within 7 days from the moment the first patient is identified in the outbreak.

Children who have not been vaccinated against mumps (who have not reached the vaccine age or have not received vaccination due to medical contraindications or refusal to vaccinate), no later than the 5th day from the moment of contact with the patient, is injected with normal human immunoglobulin in accordance with the instructions for its use. Information about the vaccinations carried out and the introduction of immunoglobulin (date, name of the drug, dose, batch, control number, expiration date, manufacturer) is entered into the accounting forms in accordance with the requirements for the organization of vaccine prophylaxis.
Specific prophylaxis is carried out with the live vaccine KKP at 12 months, revaccination - at 6 years.

Patient monitoring:
· Repeated examination by the local doctor after 2 days or earlier, if the patient becomes worse, there is a fever above 38 ° C, repeated vomiting, severe headache, drowsiness, lethargy;
· Inform the patient in what situation it is necessary to consult a doctor again;
Send the patient to hospital treatment: in case of complications from the nervous system (impaired consciousness, delirium, convulsions, meningeal symptoms), gastrointestinal tract (pain in the upper abdomen, repeated vomiting), genitourinary system (pain in the groin area, increase testicles).

Treatment efficacy indicators

· No complications.

Treatment (hospital)

STATIONARY TREATMENT

Treatment tactics

Drug-free treatment :
· Regime: bed in the acute period of the illness (7-10 days).
· Diet №2: drink plenty of water, sour fruit juices and fruit drinks, water with lemon juice (to stimulate the secretion of saliva by the salivary glands). Food is liquid, semi-liquid, dairy-vegetable, restriction of bakery, pasta, fatty, fried foods, cabbage. Black bread, rice, potatoes are allowed.
· Dry heat locally on the area of ​​the salivary glands.
· Care for the oral cavity, rinsing the oropharynx (warm boiled water, decoction of herbs, 2% sodium bicarbonate solution, antiseptics) 4-6 times a day.
· With orchitis - wearing a suspensor.

Drug treatment
Etiotropic therapy not developed.

Detoxification therapy:
With a moderate course of the disease without complications - drink plenty of fluids at the rate of 20-40 ml / kg;
In severe disease with complications - infusion therapy - the introduction of isotonic (0.9% sodium chloride solution, 400; 5% dextrose solution, 400.0) and colloidal (meglumine sodium succinate, 400.0) solutions in a ratio of 3-4 : 1 in a total volume of 1200-1500 ml for 3-5 days.

Desensitizing therapy:
one of the following drugs:
· Chloropyramine 25 mg, 1 tablet by mouth 3 times a day, 5-7 days [UD - C];
or
· Cetirizine 5 mg, 10 mg, 1 tablet by mouth 1 time per day, 5-7 days [LEO-B];
or
· Loratadine 10 mg, 1 tablet by mouth 1 time per day, 5-7 days [UD-B].

Vitamin therapy for the regulation of redox processes, antioxidant purpose:
Ascorbic acid 50 mg, 2 tablets inside 3 times a day, course for 2 weeks.
Symptomatic therapy:
With an increase in body temperature more than 38.0 ° C:
one of the following drugs:
· Ibuprofen 200 mg, 400 mg, 1 tablet by mouth 3-4 times a day, until the fever subsides [LE - A];
or
· Diclofenac 75 mg / 2 ml, IM [UD - A];
or
· Paracetamol 500 mg, 1 tablet by mouth, with an interval of at least 4 hours [DD - A].

Pathogenetic treatment of mumps with complications

Serous meningitis	Pancreatitis	Orchitis	Bacterial complications
GCS therapy -Prednisolone, ampoules 30 mg / ml, 25 mg / ml for the calculation of 2 mg / kg / day. i / v, i / m; -Dexamethasone, ampoules 4 mg / ml at the rate of 0.2 mg / kg / day, the course of treatment is up to 3 days. Dehydration therapy from 4-5 days of illness Furosemide, ampoules of 10 mg / ml, 2.0 ml (in severe cases, up to 100 mg / day), the course of treatment is 1-3 days; -mannitol (10, 15 and 20%) - 400.0 ml i.v. drops for 10-20 minutes. (with the threat of cerebral edema); -acetazolamide 250 mg, 1 tablet per day	Antisecretory therapy One of the following drugs -Pantoprazole 20mg, 40 mg orally 2 times a day, -Omeprazole 20 mg, 40 mg 2 times a day. Protease inhibitors -Aprotinin 10,000 IU, ampoules, intravenous drip, course 5-7 days. Treatment of insufficiency of exocrine pancreatic function -Pancreatine 10,000, 25,000 U for a meal	GCS therapy Prednisol on 5 mg, orally 40-60 mg for 5-7 days, followed by a daily dose reduction of 5 mg	Antibacterial therapy One of the following drugs -Amoxicillin + clavulonic acid 500/125 mg, 875/125 mg 1 tablet 2-3 times a day, course 7-10 days; - Cefazolin powder for preparation of solution for injection in a bottle 1 g, 2 g 2-3 times a day i / m, i / v, course 7-10 days; - Ceftriaxone powder for solution for injection in a bottle 1 g, 2 g 2-3 times a day i / m, i / v, course 7-10 days.

Essential Medicines List
· Ascorbic acid, 50 mg, tablets by mouth [UD - C].

List of Complementary Medicines
· Ibuprofen 200 mg, 400 mg tablets by mouth [UD-A];
· Or diclofenac 75 mg / 2 ml, v / m ampoules [UD - A].
· Or paracetamol 500 mg, tablets by mouth [DD - A].
· Chloropyramine 25 mg, tablets by mouth [UD - C];
· Or cetirizine 5 mg, 10 mg tablets by mouth [UD-B],
· Or loratadine 10 mg oral tablet [LE-B].
· Prednisolone, 30 mg / ml, 25 mg / ml, ampoules in / m, in / in;
Dexamethasone, 4 mg / ml, ampoules i / m, i / v;
Furosemide, 10 mg / 2.0 ml, v / m, i / v ampoules;
Mannitol 10, 15 and 20% 400.0 ml bottle, IV;
Acetazolamide 250 mg tablets by mouth;
Pantoprazole 20, 40 mg tablets, or
Omeprazole 20, 40 mg tablets;
Aprotinin 10,000 IU, ampoules, i.v.
Pancreatin 10,000, 25,000 IU, capsules;
Amoxicillin + clavulonic acid 500/125 mg, 875/125 mg tablets or
Cefazolin powder for preparation of solution for injection in a vial of 1 g, 2 g i / m, i / v, or
Ceftriaxone powder for solution for injection in a bottle of 1 g, i / m, i / v;
0.9% sodium chloride solution, 400, IV bottle;
5% dextrose solution, 400.0, IV bottle;
Meglumine sodium succinate, 400.0, vial.

Surgical intervention:
· In severe orchitis - dissection of the white membrane of the testicle.

Other treatments: no.

Indications for specialist consultation
· Consultation with a surgeon: for differential diagnosis with acute surgical diseases of the abdominal cavity, resolving the issue of surgical treatment of severe orchitis;
· Consultation of an endocrinologist: with the development of diabetes mellitus and obesity in the outcome of mumps;
· Consultation of a gastroenterologist: in case of damage to the pancreas;
· Consultation of a urologist: in case of damage to the sex glands and prostate gland;
· Consultation of an obstetrician-gynecologist: in case of epidemic parotitis in pregnant women, in persons with lesions of the female genital glands;
· Consultation of a clinical pharmacologist: for correction and justification of treatment.

Indications for transfer to the intensive care unit and intensive care unit
· Severe forms of mumps with severe neurological disorders, the development of emergency conditions (respiratory, cardiovascular failure, signs of depression of consciousness).

Treatment effectiveness indicators:
Relief of symptoms of the disease;
· No complications;
· Normalization of laboratory parameters - UAC, biochemical blood test;
· Restoration of working capacity.

Further management:
· Control over the discharge and the establishment of dispensary observation of convalescents. The discharge of the patient from the hospital after suffering from mumps is carried out according to clinical indications and in the absence of complications not earlier than 9 days from the onset of the disease. Patients who have undergone mumps with complications are subject to dispensary observation by the appropriate specialists, who determine the program and period of dispensary observation, removal from dispensary registration after persistent disappearance of residual phenomena.

Hospitalization

Indications for planned hospitalization: no.

Indications for emergency hospitalization(infectious diseases hospital / department - boxes or small wards):
· Moderate and severe forms with complications;
· The presence of risk factors (chronic diseases, immunodeficiency states);
· Epidemiological indications - persons living in family hostels, communal apartments, unfavorable social conditions.

Information

Sources and Literature

1. Minutes of the meetings of the Joint Commission on the Quality of Medical Services of the Ministry of Healthcare of the Republic of Kazakhstan, 2016
   1. 1) Infectious diseases: national guidelines. / Ed. N. D. Yushchuk, Yu. Ya. Vengerova. M .: GEOTAR-Media, 2009, pp. 441–53. 2) Guidelines for Infectious Diseases. / Ed. Corresponding Member RAMS, prof. Yu.V. Lobzin. 3rd edition, supplemented and revised. - SPb: Foliant, 2003.-936 p. 3) Amireev S.A., Bekshin Zh.M., Muminov T.A. and others. Standard case definitions and algorithms of measures for infectious diseases. Practical guide, 2nd edition revised. - Almaty, 2014 - 638 p. 4) Duysenova A.K., Shokalakova A.K., Sadykova A.M., Abildaeva I.Zh., Imanbaeva A.E. Features of the course of mumps infection in adults according to the materials of the GKIB them. I.S. Zhekenova. / Journal "Medicine" .- No. 12.-2014.-P.63-66. 5) Clinical and laboratory diagnostics of infectious diseases. / Ed. Yu.V. Lobzin. A guide for doctors. - SPb: Foliant, 2001.-384 p. 6) Epidemic parotitis. Modern ideas about the pathogen, clinical picture, diagnostics, prevention. / Ed. A.P. Agafonov. - Novosibirsk: CJSC "Medico-biological Union", 2007.-82 p. 7) Clinical guidelines for the provision of medical care to children with epidemic parotitis / Public organization "Eurasian Society for Infectious Diseases", chairman Yu.V. Lobzin, 2015.

Information

Abbreviations used in the protocol

Ig G immunoglobulins G
Ig M immunoglobulins M
BP blood pressure
ELISA enzyme-linked immunosorbent assay
IU International Units
KLA complete blood count
OAM general urinalysis
PCR polymerase chain reaction
RNA ribonucleic acid
CSC reaction of complement fixation
RTGA reaction of inhibition of hemagglutination
CSF cerebrospinal fluid
ESR erythrocyte sedimentation rate
Ultrasound ultrasound
ECG electrocardiography
EEG echoencephalophia

List of protocol developers:
1) Kosherova Bakhyt Nurgalievna - Doctor of Medical Sciences, Republican State Enterprise at RKhV "Karaganda State Medical University", professor, vice-rector for clinical work and continuous professional development, chief freelance infectious disease specialist of the Ministry of Health and Social Development of the Republic of Kazakhstan.
2) Kim Antonina Arkadyevna - Candidate of Medical Sciences, Republican State Enterprise at the REM "Karaganda State Medical University", Associate Professor, Head of the Department of Infectious Diseases and Dermatovenereology.
3) Nurpeisova Ayman Zhenayevna - PSE "Polyclinic No. 1" of the Health Department of Kostanay region, head of the hepatological center, infectious disease doctor of the highest category, chief freelance infectious disease specialist.
4) Mazhitov Talgat Mansurovich - Doctor of Medical Sciences, JSC "Astana Medical University", Professor of the Department of Clinical Pharmacology and Internship.

Conflict of interests: absent.

List of reviewers: Doskozhaeva Saule Temirbulatovna - Doctor of Medical Sciences, JSC "Kazakh Medical University of Continuing Education", Vice-Rector for Academic Affairs, Head of the Department of Infectious Diseases with a course of children's infections.

Terms of revision of the protocol: revision of the protocol 3 years after its publication and from the date of its entry into force or in the presence of new methods with a level of evidence.

Attached files

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The incubation period varies from several days to a month, more often it lasts 18-20 days.
In children, quite rarely, a short (1-3 days) prodromal period may develop after it, manifested by chilling, headache, pain in muscles and joints, dry mouth, unpleasant sensations in the parotid salivary glands. More often, the disease begins acutely with chills and an increase in body temperature from subfebrile to high numbers; fever persists for no more than 1 week. However, cases of the disease occurring with normal body temperature are not uncommon. Fever is accompanied by headache, general weakness, malaise, insomnia. The main manifestation of mumps is inflammation of the parotid, and possibly the submandibular and sublingual salivary glands. In the projection of these glands, a swelling appears, painful on palpation (more in the center), having a pasty consistency. With a pronounced increase in the parotid salivary gland, the patient's face becomes pear-shaped, the earlobe rises on the affected side. The skin in the area of ​​swelling is taut, shiny, hardly folds, its color is usually not changed. Most often, the process is bilateral, involving the parotid gland in 1-2 days and on the opposite side, but unilateral lesions are also possible. The patient is disturbed by a feeling of tension and pain in the parotid region, especially at night; when the tumor compresses the Eustachian tube, noise and pain in the ears may appear. When pressed behind the earlobe, severe soreness appears (Filatov's symptom). This symptom is the most important and early sign of mumps. The mucous membrane around the opening of the stenonic duct is hyperemic and edematous (Mursu's symptom); hyperemia of the pharynx is often noted. In some cases, the patient cannot chew food due to pain, and in even more severe cases, functional trismus of the chewing muscles develops. Possible decrease in salivation and dry mouth, hearing loss. The pain lasts 3-4 days, sometimes radiating to the ear or neck, and gradually subside by the end of the week. Approximately by this time or a few days later, the swelling in the projection of the salivary glands disappears. With mumps, regional lymphadenopathy is usually not noted.
In adults, the prodromal period is noted more often, it is characterized by more pronounced clinical manifestations. In addition to general toxic ones, catarrhal and dyspeptic phenomena are possible during this period. The acute phase of the disease is usually more severe. Much more often than in children, lesions (possibly isolated) of the submandibular and sublingual salivary glands are observed. In submaxillitis, the salivary gland has a doughy consistency and is slightly painful, extended along the lower jaw, which is recognized when the head is tilted back and to the side. Edema of the subcutaneous tissue around the gland sometimes extends to the neck. Sublingualis is manifested by swelling in the chin region of the same nature, pain under the tongue, especially when it protrudes, local hyperemia and swelling of the mucous membrane. Swelling in the projection of the salivary glands in adults lasts longer (2 weeks or more).

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Disease code - B26 (ICD 10)

Syn .: mumps, mumps
Epidemic parotitis (parotitis epidemica) is an acute viral disease characterized by fever, general intoxication, enlargement of one or more salivary glands, and often damage to other glandular organs and the nervous system.

Historical background

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Mumps was described by Hippocrates in the 5th century. BC. Hamilton (1790) identified the symptoms of CNS damage and orchitis as frequent manifestations of the disease. At the end of the XIX century. summarized data on the epidemiology, pathogenesis and clinical picture of mumps. A great contribution to the study of this problem was made by domestic scientists I.V. Troitsky, A.D. Romanov, N.F. Filatov.

In 1934, the viral etiology of the disease was proved.

Etiology

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Causative agent mumps infection belongs to the family Paramyxoviridae, genus Paramyxovirus, has a size of 120 x 300 nm. The virus contains RNA, has hemagglutinating, neuraminidase and hemolytic activity.

Antigenic structure the virus is stable.

Under laboratory conditions, the virus is cultivated in 7–8-day-old chicken embryos and cell cultures. Laboratory animals are insensitive to the causative agent of mumps. In the experiment, only in monkeys it is possible to reproduce a disease similar to human mumps.

Stability. The virus is unstable, inactivated by heating (at a temperature of 70 ° C for 10 min), ultraviolet irradiation, exposure to low concentration formalin and lysol solutions. Keeps well at low temperatures (–10–70 ° С).

Epidemiology

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Source of infection is a sick person, including an erased and asymptomatic form of mumps. The patient is contagious in the last days of the incubation period, in the prodromal period and in the first 5 days of the height of the disease. Reconvalescents are not sources of infection.

The mechanism of infection. Infection occurs by airborne droplets, the virus is excreted in saliva. Transmission of infection through infected household items and toys is allowed. In some cases, intrauterine infection with the mumps virus is described - the vertical route of transmission.

Mostly children are ill at the age of 1 year - 15 years, boys are 1.5 times more likely than girls. Persons who have not had mumps remain susceptible to it throughout their lives, which leads to the development of the disease in different age groups.

Seasonal rise in incidence is typical at the end of winter - in spring (March - April). The disease occurs both in the form of sporadic cases and epidemic outbreaks.

Mumps infection is one of the most common viral diseases that occurs in all countries of the world.

After the transferred disease, a strong specific immunity remains.

Pathogenesis and pathological picture

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Entrance gate infections serve the mucous membranes of the upper respiratory tract and possibly the oral cavity. After accumulation in epithelial cells, the virus enters the bloodstream (primary viremia) and spreads with its current to various organs and tissues. The virus, hematogenously introduced into the salivary glands, finds optimal conditions for reproduction here and causes a local inflammatory reaction. Reproduction of the virus also occurs in other organs, but much less intense. As a rule, damage to other glandular organs (testicles, pancreas) and the nervous system does not develop from the first days of the disease, which is associated with the slow replication of the virus in them, as well as secondary viremia, which is a consequence of the intense multiplication of the virus and its release into the blood from the inflamed parotid salivary glands. In the development of complications, the functional state of organs is important (for example, weakening of the blood-brain barrier), as well as immune mechanisms (circulating immune complexes, autoimmune reactions).

Pathological picture uncomplicated mumps has been studied insufficiently due to the benign course of the disease. Parotid tissue retains an acinous structure, but edema and lymphocyte infiltration are noted around the salivary ducts. The main changes are localized in the ducts of the salivary glands - from a slight edema of the epithelium to its complete desquamation and obstruction of the duct with cellular detritus. Suppurative processes are extremely rare.

Testicular biopsy in mumps orchitis revealed lymphocytic infiltration and interstitial tissue, hemorrhagic foci. Often there are foci of necrosis of the glandular epithelium with blockage of the tubules with cellular detritus, fibrin and leukocytes. In severe cases, after inflammation, ovarian atrophy may occur. Inflammatory-degenerative processes are described in the ovaries.

Changes in the pancreas are not well understood. There is evidence of the possibility of developing necrotizing pancreatitis with damage to both the endocrine and exocrine tissue of the gland, in severe cases, followed by its atrophy. CNS lesions are non-specific.

Clinical picture (Symptoms) of mumps

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The incubation period ranges from 11 to 23 days (usually 15–19 days).

The prodromal period is rare.

Within 1-2 days, patients complain of malaise, general weakness, weakness, chills, headache, pain in muscles and joints, loss of appetite.

In typical cases, there is an acute onset of the disease with an increase in body temperature to 38–40 ° C and the development of signs of general intoxication. Fever often reaches its maximum severity on the 1–2 nd day of illness and lasts 4–7 days, followed by a lytic decrease.

The defeat of the parotid salivary glands is the first and characteristic sign of the disease ... There is swelling and soreness in the parotid glands, first on one side, then on the other. The process may also involve other salivary glands - submaxillary and sublingual. The area of ​​the enlarged gland is painful on palpation, soft-doughy consistency. The pain is especially pronounced at some points: in front and behind the earlobe (Filatov's symptom) and in the area of ​​the mastoid process.

The symptom of Mursa (Murson) is of diagnostic value - hyperemia, an inflammatory reaction of the mucous membrane in the area of ​​the excretory duct of the affected parotid gland. Hyperemia and swelling of the tonsils are possible. The swelling can spread to the neck, the skin becomes tense, shiny, there is no hyperemia. Patients are worried about pain when chewing. In some cases, reflex trismus occurs, which interferes with talking and eating. With unilateral damage to the salivary glands, the patient often tilts his head towards the affected gland. The enlargement of the salivary gland progresses rapidly and reaches a maximum within 3 days. The swelling lasts 2-3 days and then gradually (within 7-10 days) decreases. Against this background, various, often severe, complications can develop. There is no unified idea of ​​how to consider lesions of various organs in mumps - as manifestations or complications of the disease. There is no generally accepted classification of mumps. A.P. Kazantsev (1988) proposes to distinguish complicated and uncomplicated forms of the disease. According to the severity of the course - mild (including erased and atypical), moderate and severe forms. The inapparent (asymptomatic) form of the disease is of great importance in the epidemiology of the disease. There are residual phenomena of mumps, which include such consequences as deafness, testicular atrophy, infertility, diabetes mellitus, and dysfunction of the central nervous system.

The form of the severity of the disease is determined on the basis of the severity of the syndrome of intoxication. In severe form, along with signs of intoxication, hyperthermia, patients develop nausea, vomiting, diarrhea as a result of damage to the pancreas; enlargement of the liver and spleen is less common. The more severe the course of the disease, the more often it is accompanied by various complications.

Complications

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Development of meningitis, meningoencephalitis, orchitis, acute pancreatitis, arthritis, myocarditis, etc. is possible.

Serous meningitis

Serous meningitis - the most frequent and characteristic complication of mumps, which occurs after inflammation of the salivary glands or, less often, simultaneously with it, at different times from the onset of the disease, but more often after 4-10 days. Meningitis begins acutely, with the appearance of chills, a repeated rise in body temperature (up to 39 ° C and above). Patients are worried about severe headache, vomiting, pronounced meningeal syndrome develops (stiff neck, positive Kernig, Brudzinsky symptom). Cerebrospinal fluid is clear, colorless, and flows out under increased pressure. In the cerebrospinal fluid, typical signs of serous meningitis are found: lymphocytic pleocytosis up to 500 and less often 1000 in 1 μl, a slight increase in protein content at normal levels of glucose and chlorides. After the extinction of the symptoms of meningitis and intoxication, the sanation of cerebrospinal fluid occurs relatively slowly (1.5–2 months or more).

Some patients develop clinical signs. meningoencephalitis: impaired consciousness, lethargy, drowsiness, uneven tendon reflexes, paresis of the facial nerve, lethargy of pupillary reflexes, pyramidal signs, hemiparesis, etc. The course of meningoencephalitis of mumps etiology is predominantly favorable.

Orchitis and epididymitis

Orchitis and epididymitis most common in adolescents and adults. They can develop both in isolation and jointly. Orchitis is observed, as a rule, after 5-8 days from the onset of the disease and is characterized by a new rise in body temperature, the appearance of severe pain in the scrotum and testicle, sometimes with irradiation to the lower abdomen. Involvement of the right testicle in the process sometimes stimulates acute appendicitis. The affected testicle is significantly enlarged, becomes dense, the skin above it swells and turns red. The enlargement of the testicle lasts 5-8 days, then its size decreases, the pain disappears. Later (after 1–2 months), some patients may show signs of testicular atrophy.

Oophoritis

Oophoritis rarely complicates mumps, accompanied by pain in the lower abdomen and signs of adnexitis.

Acute pancreatitis

Acute pancreatitis develop on the 4-7th day of illness. The main symptoms: sharp pains in the abdomen with localization in the mesogastrium, often cramping or shingles, fever, nausea, repeated vomiting, constipation or diarrhea. Amylase levels increase in blood and urine.

Damage to the organ of hearing

Damage to the organ of hearing rare but can lead to deafness. There is a predominantly unilateral lesion of the auditory nerve. The first signs are tinnitus, then manifestations of labyrinthitis join: dizziness, impaired coordination of movement, vomiting. Hearing usually does not recover.

Rare complications include myocarditis, arthritis, mastitis, thyroiditis, bartholinitis, nephritis, etc.

Forecast

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Usually auspicious.