Fever and Neck Pain in a College Student

February 1, 2009

A 22-year-old man seeks medical attention at his college’s infirmary. He had been in excellent health until 1 week earlier, when he noted onset of fever, headache, and malaise.

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A 22-year-old man seeks medical attention at his college’s infirmary. He had been in excellent health until 1 week earlier, when he noted onset of fever, headache, and malaise. After a few days, pain and swelling developed on the left side of his neck beneath the angle of the jaw. His illness became severe enough that he missed classes. He denies cough and sputum production, and he has not had any GI symptoms. He has pain on swallowing in the same area as the external neck pain and swelling, but he says this is not the pain he typically experiences with a sore throat.

History

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

Physical Examination

Temperature is 38.7°C (101.6°F); heart rate, 92 beats per minute. Sclerae are injected. No redness, swelling, or exudates are noted in the pharynx, and the tonsils are normal and symmetrical. Neck is exquisitely tender on the left side, with swelling in the angle of the left jaw. No enlarged cervical or supraclavicular lymph nodes are palpable on the left; right side of the neck is normal. Results of the remainder of the physical examination are normal.

Laboratory Results

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

Which of the following statements about this patient is most likely to be true?A. Results of a mononucleosis spot test will be positive.
B. A throat swab will reveal group A streptococcal infection.
C. The complication rate associated with his illness is 5%.
D. A review of his childhood and prematriculation vaccination history will reveal deficiencies.

(answer on next page)

Correct Answser: C

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

Several other diseases that are common in young adults also involve febrile pharyngitis or adenopathy. Pharyngitis is a nearly universal symptom of mononucleosis in this age-group. When this disease is suspected, a mononucleosis spot test (choice A) is appropriate; it is about 97% specific for mononucleosis. However, impressive tonsil swelling and severe exudative pharyngitis are the rule in mononucleosis; their absence here makes that diagnosis unlikely.

Although the physical findings in streptococcal pharyngitis (choice B) can be more subtle than those associated with mononucleosis, patients typically have a much more specific history of pharyngitis than was seen here. Also, leukocytosis, even with a left shift, would be expected, and this young man’s white blood cell count was normal.

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

Then, in 2006, a series of outbreaks occurred on college campuses in the United States.3,4 These epidemics were studied in detail, revealing the following:

•The strain of mumps virus involved was mainly genotype G, a common strain against which the mumps vaccine is effective; thus, the resurgence was not caused by a new or resistant strain of mumps virus.

•Among US adolescents, 87% had 2-dose coverage in 2006, which should have been adequate to provide herd immunity and thus prevent outbreaks or epidemics.

(Thus, choice D, which implies that this patient had not been properly vaccinated, is probably false.)

The most likely cause of the reemergence of mumps is the waning of immunity in populations in which susceptible subjects are brought together and live in close proximity. Thus, either a more effective mumps vaccine (ie, one that provides longer-lasting immunity) or updated mumps vaccine scheduling (eg, additional doses) might prevent similar outbreaks in the future. These strategies are currently under study by the CDC.

This patient is typical of those involved in the 2006 outbreaks. He had received 2 doses of mumps vaccine- one in childhood and one in adolescence. Most likely his immunity had decayed in subsequent years, and when in college, in close proximity to others with a similar immune status, he was susceptible to contracting the disease.

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

For the most part, the illness is self-limited; however, complications do occur in 5% of patients (choice C). Orchitis is by far the most common of these; the more serious complications-meningitis, encephalitis, and deafness- occur in about 1% of patients.1

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

References:

References

:

1

. Dayan GH, Quinlisk MP, Parker AA, et al. Recent resurgence of mumps in the United States.

N Engl J Med.

2008;358:1580-1589.

2

. Mumps vaccine.

MMWR.

1977;26:393-394.

3

. Centers for Disease Control and Prevention. Mumps epidemic-Iowa, 2006.

MMWR.

2006;55:366-368.

4

. Centers for Disease Control and Prevention. Update: multistate outbreak of mumps-United States, January 1 – May 2, 2006.

MMWR.

2006:55:559-563.