| Abstract|| |
Mumps is an infection caused by paramyxoviruses. This infection is more common among children and it progresses with a number of complications later in life. This case was found worth presenting because no cases with such a diversity of complications have been reported in English literature in the last 25 years.
A 17-year-old male patient was admitted to the emergency unit with bilateral parotitis, meningoencephalitis and orchitis. The patient was clinically and serologically diagnosed as having mumps and developed an acute pancreatitis, arthritis in the left knee, cholestatic hepatitis and myocarditis in the follow up. Radiological imaging methods lead the way to the description of the complications.
Keywords: Mumps, Meningoencephalitis, Orchitis, pancreatitis, myocarditis
|How to cite this article:|
Sirmatel O, Yazgan P, Sirmatel F, Ozturk A, Ziylan Z. Radiological findings in a mumps case with multiple complications. Indian J Radiol Imaging 2006;16:305-8
|How to cite this URL:|
Sirmatel O, Yazgan P, Sirmatel F, Ozturk A, Ziylan Z. Radiological findings in a mumps case with multiple complications. Indian J Radiol Imaging [serial online] 2006 [cited 2014 Nov 27];16:305-8. Available from: http://www.ijri.org/text.asp?2006/16/3/305/29002
| Introduction|| |
Mumps is a viral disease that is caused by paramyxoviruse and progresses with epidemic parotitis in the childhood period. The most common complications expected during the course of the disease are meningoencephalitis, orchitis, myocarditis, hepatitis and acute pancreatitis . Mumps is defined as the most common cause of acute pancreatitis in childhood . Acute pancreatitis has even been reported as a complication of vaccination in developed countries . Complications are more likely to occur in acute mumps infections in the elderly. Radiological imaging methods are very beneficial in describing the complications of mumps infection ,.
We observed more than one complication in a patient with acute mumps infection and benefited from radiological imaging methods for the diagnosis of these complications.
A search in English literature revealed no other mumps cases with concurrent encephalitis, orchitis, acute pancreatitis, cholestatic hepatitis and myocardial complications . This case is presented for the discussion of mumps complications from a radiological point of view, enlightened by knowledge from literature.
| Case report|| |
A 17-year-old male patient was admitted to the emergency unit with nausea and vomiting. History revealed an outbreak of mumps in the village where the patient lived and his complaints had developed within the last two days. On physical examination, the patient was unconscious, had neck stiffness, his temperature was 38°C, his blood pressure was normal; he had bilateral swellings in the parotid regions and findings of unilateral orchitis. The patient was taken to the intensive care unit for the clinical follow-up of acute epidemic parotitis, orchitis and meningoencephalitis. Initial laboratory analyses for blood biochemistry and complete blood count were within normal limits. Diagnostic lumbar puncture revealed increased pressure of cerebrospinal fluid, increased protein (85% mg, the normal range being 20-40% mg) and dominance of lymphocytes in the cell population (506 cells/mm3). The patient was hospitalized in the intensive care unit with the diagnoses of mumps-related meningitis and orchitis. He was transferred to the regular ward after he regained consciousness within on the 3rd day in the intensive care unit. During the follow-up, he complained about severe nausea and vomiting associated with a band-like back pain, shortness of breath, palpitation and swelling in his left knee. Meanwhile his blood biochemistry was distorted as follows: Blood glucose 192 mg/dl (n 120), amylase 512 u/l (n 25-125), enzymes indicative of tissue destruction including LDH 329 u/L (n 100-190), CPK 1121 u/l (n 38-174), and CK-MB 75 u/l (n 2-6). The patient was clinically prediagnosed as suffering from acute pancreatitis, arthritis and myocarditis.
His oral intake was ceased. Diagnosis was confirmed by abdominal ultrasound (US) and abdominal computed tomography (CT). The echocardiographic (ECHO) and electrocardiographic findings (ECG) were consistent with viral myocarditis. He was treated symptomatically with analgesics, anti-inflammatory agents and balanced fluid and electrolyte solutions. When necessary, crystallized insulin was administered to regulate blood glucose. Specifically, ribavirin (1.2 g/day for 10 days) was administered as an antiviral agent.
The patient was evaluated as a complicated mumps case that presented with findings of viral meningoencephalitis, orchitis, acute pancreatitis, hepatitis, arthritis and myocarditis. Mumps IgG and IgM were serologically positive. Furthermore, the clinical picture was evaluated in detail by radiological imaging methods.
Parotid US revealed multiple intraparanchymal, hypoechoic lymph nodes in both parotid glands. These lymph nodes were well-circumscribed and their central portions were hyperechoic.
Brain magnetic resonance imaging (MRI) axial T-2 weighted imaging, (T2WI) performed to confirm the diagnosis of meningoencephalitis, revealed dilatations in the lateral and 3rd ventricles as well as edema in the periventricular region, which was observable also in the axial flair, MRI. Sagittal T-1 weighted imaging (T1WI) revealed dilated lateral ventricles [Figure - 1]A, B and C. Increases in volume and blood supply, and decreases in the echogenicity and resistive indices of intratesticular arteries (RI 47) of the left testis were detected by testicular US and color Doppler ultrasound (CDUS).The patient had minimal hydrocele as well as edema in the skin [Figure - 2]. An abdominal US was performed when the patient began to complain of abdominal pain, which revealed thickening in the wall of the gall bladder, an increase in the dimensions of pancreas beyond normal (28 mm) and a decrease in the echogenicity of the pancreas as compared to the liver. Furthermore, pancreatic dimensions were increased and pancreatic contours were blurred in the abdominal CT [Figure - 3].
The bradycardic episode (62 beats/min) observed concomitantly with acute pancreatitis was assumed to be related to myocarditis, which was confirmed by ECHO and ECG.
The patient was discharged with relief 20 days after admission. The control visit on the 3rd month revealed perfectly normal findings.
| Discussion|| |
Radiological studies with a wide series of patients showed enlargement of the parotid gland and presence of intraparenchymal hypoechoic lymph nodes in mumps cases ,. The parotid US of the presented case revealed multiple lymph nodes, a finding which was consistent with those in literature.
Despite claims in literature that increased CRP levels may be found in patients with mumps related meningitis and orchitis , CRP levels of the presented case were not elevated.
Examination of the cerebrospinal fluid is diagnostic for cases of viral meningoencepahalitis. In particular, computed tomography (CT) and magnetic resonance imaging (MRI) facilitate the diagnosis in viral cases. Viral meningitis is observed in 40 to 70% of mumps cases . Some cases may end up with hydrocephalus in late stages . MRI is more sensitive than CT in detection of encephalitis, demonstrating normal brain structures at the early phases of the disease ,. (In the present case, brain MRI revealed a hypointense image at T1WI and a hyperintense image at T2WI, and flair MRI. There were dilatations of the lateral and 3rd ventricles as well as periventricular edema on the axial T2WI cranial MRI. There was periventricular edema on axial flair MRI and dilatation of the lateral ventricle on sagittal T1W1. The demonstration of ventricular dilatation on MRI in an acute case is the first in literature.
In the present case, hydrocephalus, a condition which presents as a late complication of mumps ,, was detected and treated at the early stages of the disease.
The ultrasound findings are not specific for mumps-related orchitis ,,. However, 14 - 35% of cases with mumps-related orchitis exhibit bilateral involvement of the testes and the involved testes show enlargement with decreased echogenicity . In a study conducted in our country, 9 of 11 mumps-related orchitis cases were unilateral and the findings in the involved testes were decreased echogenicity, increased volume and vascularization, and the best methods for detecting the venous blood flow was found to be color Doppler ultrasonography (CDUS) . Involved testes exhibit increase in volume and vascularization, decrease in echogenicity and the resistive indices of intratesticular arteries (RI), as well as venous blood flow [11,12]. Mumps-related testicular involvement may also be observed in the form of reactive hydrocele, thickening of scrotal skin and edema . Traumas, infarcts and inflammatory intratesticular abscesses cause secondary orchitis. On US, these are observed with irregular walls located inside the testis, have low levels of echogenicity and vascularized borders . Hyperemia and heterogenicity may accompany tumors and infarcts other than orchitis. CDUS is more sensitive than US in detecting testicular infection ,. In a study conducted by Tarantino et al , 68 cases were evaluated and the inflammatory testicular parenchyme was found to be hypervascular, in addition to significantly lower resistive indices (RI) than in a normal testis. RI was found to be in the range of 0.48-0.57 on the infected side and 0.71-0.60 on the normal side.
The US and the CDUS examinations of the present case revealed increased volume and vascularization in the left testis, decreased resistive indices of intratesticular arteries (RI) and a venous flow. The patient had minimal hydrocele besides edema of the skin. US may not be explanatory in detecting acute pancreatitis because of the gas shadow. However, abdominal CT may reveal focal or diffuse enlargement of pancreas, blurring, minimal fluid accumulation in the neighboring tissue, as well as an image of an abscess or a pseudocyst in complicated cases ,. Balthazar et al  stratified the image of acute pancreatitis in five categories. The abdominal CT findings of the present case were consistent with grade 2 acute pancreatitis with enlargement of the pancreas (28 mm) and blurring in the contours.
Subclinical cases of mumps may progress with arthritis as rarely as 0.5% . This form of arthritis does not respond to analgesic therapy. However our case benefited from analgesics for arthritis.
The most important complication of mumps is myocarditis ,. It may be fatal causing congestive cardiac failure and cardiomyopathy, developing months after the disease . The patient recovered fully with no further complication other than myocarditis.
The US, CDUS, CT and MRI findings of our patient, who presented with complications of mumps including meningoencephalitis, orchitis, acute pancreatitis and mycarditis, were consistent with those in literature. Cases of mumps and pancreatitis, mumps and myocarditis, mumps and orchitis, or mumps and meningoencephalitis are present in literature. Imaging methods will help the clinician follow mumps cases and determine the complications, to which the elderly are more susceptible.
| References|| |
|1.||Anil B. Nagor, Fred S. Gorecelik. Acute pancreatitis Curr Opin Gastroenterol 2004 ; 20(5): 439-43 |
|2.||Haddock G, Couper G, Youngson GG, Mac Kinlay GA, Raine DA. Acute pancreatitis in children: :a 15 year review . J Pediatr Surg 1994; 29(6): 719-22 |
|3.||Ortiz A. An acute pancreatitis probably due to mumps complicated by obstructive jaundice Rev Med Chil 1983; 111(5): 493-94 |
|4.||Nicolic P, Apostolski A, Kaljalovic R, Bojic I. Acute myocarditis and orchitis during mumps virus infection . Vojnosanit Pregl 1978; 35(6): 448-50 |
|5.||Lowe LH, Stokes LS, Johnson JE, Heller RM, Swelling at the Angle of the Mandible: Imaging of the Pediatric Parotid Gland and Periparotid Region Radiographics.2001; 21:1211-1227 |
|6.||Tarantino L, Giorgio A, de Stefano G, Farella N. Echo color Doppler findings in postpubertal mumps epididymo-orchitis. J Ultrasound Med.2001; (11):1189-95. |
|7.||Unal A, Emre U, Atasoy HT, Sumer MM, Mahmutyazicioglu K. Encephalomyelitis following mumps. Spinal Cord 2005; 8:215-17 |
|8.||Kabakas N, Aydinoglu H, Yekeler H, Arslan IN. Fatal mumps nephritis and myocarditis. Trop Pediatr 1999; 47(6): 358-60 |
|9.||Silva ML, Baiao Filho TL, Fernandez VR, Lopes SL, Chang ML. Post-parotitis myocarditis case report. Pediatr (Rio J) 2000; 72(5): 345-8 |
|10.||Feldman G, Zer M. Infantile acute pancreatitis after mumps vaccination simulating an acute abdomen Pediatr Surg Int 2000; 16(7): 488-89 |
|11.||Dogra VS, Gottlieb RH, MD, Oka M, Rubens DJ. Sonography of the Scrotum Radiology 2003; 227:18-36. |
|12.||Basekim CC, Kizilkaya E, Pekkafali Z, Baykal KV, Karsli AF. Mumps epididymo-orchitis: sonography and color Doppler sonographic findings. Abdom Imaging 2000; 25:322-325 [PUBMED] [FULLTEXT]|
|13.||Tarantino L, Giorgio A, De Stefeno G, Farella N. Ultrasonography in the diagnosis of post-pubertal epidemic parotitis and its complications. Radiol Med (Torino) 2000; 99(6): 461-4 |
|14.||Sonmez FM, Odemis E, Ahmetoglu A, Ayvaz A. Brainstem encephalitis and acute disseminated encephalomyelitis following mumps. Pediatr Neurol 2004; 30(2):132-34 |
|15.||Chan PT, Capoliccho G, Brzezinski A, Pippi Salle JL. Bilateral testicilar microlithiasis: case report and review of the literature. Can J Urol 1998; 5(1): 485-87 |
|16.||de Cassio Saito O, de Barros N, Chaman MC, Oliveira IR, Cerri GG. Ultrasound of tropical and infectious diseases that affect the scrotum. Ultrasound Q 2004; 20(1): 12-8 |
|17.||Ozkutlu S, S φylemezoglu O, Calikoglu AS, Kale G. Fatal mumps myocarditis. Jpn Heart J 1989; 30(1):109-14. |
|18.||Niizuma T, Terada K, Kosaka Y, Daimon Y, Inoue M, Ogita S, Kataoka N, Tanaka K. Elevated serum C-reactive protein in mumps orchitis. Pediatr Infect Dis J 2004; 23(10):971 |
|19.||Glenda Ramora Urquart. Acute pancreatitis, www. Emedicine.com topic, 2004; 521 |
|20.||Bathazar EJ, Freeny PC, vanSonnenberg E. Imaging and intervention in acute pancreatitis (1994) Radiology Medicine 1994; 193 (2): 297-306 |
School of Medicine of Harran University, Radiology Department, 63050, SANLIURFA
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]