Clinical features of mumps orchitis in vaccinated postpubertal males: a single-center series of 62 patients

Epidemiology of mumps, mumps complications, and mumps orchitis in Korea using the National Health Insurance Service database

PURPOSE

To analyze the presentation of mumps and mumps orchitis using the National Health Insurance Service Database (NHISD).

MATERIALS AND METHODS

Using information from the NHISD representing all cases of mumps in Korea, data regarding mumps orchitis were analyzed. The International Classification of Diseases, Tenth Revision, and Clinical Modification codes were used for diagnosis. The incidence estimates of the number of mumps cases were analyzed using the Statistical Analysis System (SAS) software.

RESULTS

Based on the NHISD, 199,186 people were diagnosed with mumps, and males accounted for 62.3% cases. Teen males accounted for 69,870 cases, the largest number of patients diagnosed with mumps. The annual incidence of mumps increased every year (poisson regression, hazard ratio [HR] 1.026, 95% confidence interval [CI] 1.024-1.027; p<0.025). The risk of mumps was lower in females than that in males (poisson regression, HR 0.594, 95% CI 0.589-0.599; p<0.001). Of the 199,186 patients diagnosed with mumps, 3,872 patients (1.9%) had related complications. Among the mumps complications, the most diagnosed complication was mumps orchitis, which was seen in 41.8% of the males. Mumps orchitis cases accounted for less than 1.5% of the patients with mumps in minors under the age of 20 years and was somewhat higher in 2009 and 2013-2015.

CONCLUSIONS

Among the complications related to mumps, meningitis was most common in females, while orchitis was dominant in males. Mumps orchitis also shows periodic outbreaks but is particularly prevalent in adults, which suggests the potential need for additional vaccination against mumps.

Coxsackie B virus myositis in a healthy young man with mumps co-infection

Infection is an established but uncommon etiology of myositis, and Coxsackie B virus has only been rarely described as a causative agent. We present a case of a 38-year-old male who presented with weakness, myalgias, and testicular pain following two weeks of upper respiratory infection. Laboratory tests revealed an elevated creatine kinase and positive serology for Coxsackie B4 and mumps. This unusual presentation of Coxsackie B myositis and mumps co-infection in a previously healthy young patient illustrates the importance of including infectious etiologies in the differential diagnosis and the potential life-threatening consequences of biased clinical reasoning.

[Viral infections in urology]

Einleitung

Die COVID-19-Pandemie („coronavirus disease 2019“) hat eindrucksvoll gezeigt, dass Infektionskrankheiten enorme Auswirkungen auf das Gesundheitswesen und darüber hinaus haben können. In der Urologie spielen Viren bei spezifischen Entitäten eine Rolle, wo sich der Urologe mit Viruserkrankungen beschäftigen muss.

Methodik

Diese Übersichtsarbeit hat zum Ziel in der Urologie relevante Virusinfektionen zu beschreiben und insbesondere die Impfprävention hervorzuheben. Es erfolgte eine selektive Literaturrecherche zu den Themen „COVID und Urologie“, „Urogenitale Virusinfektionen“, „Virale urologische Infektionen in der Transplantationsmedizin“ sowie „Impfprävention von Viruserkrankungen“.

Ergebnisse

Coronaviren sind Viren, die bereits 2‑mal lokale Epidemien verursacht haben (SARS- [„severe acute respiratory syndrome“] und MERS-Epidemie [„middle east respiratory syndrome“]). Die Tatsache, dass die SARS-CoV-2-Erkrankung („severe acute respiratory syndrome coronavirus 2“) auch ohne Symptome ansteckend ist, hat im Wesentlichen zu der raschen Ausbreitung und weltweiten Pandemie geführt. Eine Vielzahl von Viren, die auch eine Virämie induzieren können, wurde im Ejakulat nachgewiesen und wird damit mit einer etwaigen urogenitalen Infektion in Verbindung gebracht. Hierzu zählen u. a. das Mumps‑, Coxsackie-Viren oder Enteroviren. Es wurde auch gezeigt, dass auch eine Zika-Virusinfektion sexuell über die Spermien als Carrier übertragen werden kann. Somit spielen Viren auch eine wichtige Rolle in der Reproduktion. Bei der Nierentransplantation sind Urologen häufig mit viralen Infektionen konfrontiert. Die effektivste Waffe gegenüber Viren stellt die Impfprävention dar.

Schlussfolgerung

Äthiopathogenetisch ist der Urogenitaltrakt im Rahmen einer Virämie oder über eine Reaktivierung durch eine Immunsuppression am häufigsten mitbetroffen. Therapeutisch kommt der Immunmodulation sowie der Impfprophylaxe eine führende Rolle zu.

Mumps Orchitis: Clinical Aspects and Mechanisms

The causative agent of mumps is a single-stranded, non-segmented, negative sense RNA virus belonging to the Paramyxoviridae family. Besides the classic symptom of painfully swollen parotid salivary glands (parotitis) in mumps virus (MuV)-infected men, orchitis is the most common form of extra-salivary gland inflammation. Mumps orchitis frequently occurs in young adult men, and leads to pain and swelling of the testis. The administration of MuV vaccines in children has been proven highly effective in reducing the incidence of mumps. However, a recent global outbreak of mumps and the high rate of orchitis have recently been considered as threats to male fertility. The pathogenesis of mumps orchitis remains largely unclear due to lack of systematic clinical data analysis and animal models studies. The alarming increase in the incidence of mumps orchitis and the high risk of the male fertility have thus become a major health concern. Recent studies have revealed the mechanisms by which MuV-host cells interact and MuV infection induces inflammatory responses in testicular cells. In this mini-review, we highlight advances in our knowledge of the clinical aspects and possible mechanisms of mumps orchitis.

[Orchitis]

Orchitis can be acutely symptomatic or chronically asymptomatic. Among the acute forms is the rarer isolated orchitis, which is of viral origin in most cases as well as the more frequent secondary orchitis, which is usually the result of an ascending bacterial epididymitis. In addition, sterile forms of orchitis are also seen in patients with systemic autoimmune comorbidities. Chronic asymptomatic orchitis is the term used to describe cellular immune infiltrates in the testes, which are observed in approximately 25% of cases of azoospermia during testicular biopsy. The etiopathogenesis of these infiltrates is largely unknown with postinfection and primary pathogen-independent autoimmune reactions being discussed. Animal experimental models of orchitis may be helpful to investigate the immunological mechanisms involved as well as the therapeutic possibilities.

Evaluation and Management of Chronic Scrotal Content Pain-A Common Yet Poorly Understood Condition

Chronic scrotal content pain (CSCP) refers to bothersome pain localized to structures within the scrotum that has been present for ≥ 3 months. Etiologies include infection, trauma, and referred pain from the spine, abdomen, and retroperitoneum. However, in many patients there is no obvious identifiable cause. The initial evaluation should include a thorough history and physical examination with adjunctive imaging and laboratory tests as indicated. Treatments vary based on the underlying etiology and include both nonsurgical and surgical options with high levels of success when selectively utilized. The spermatic cord block with local anesthetic is an important tool that helps identify those patients who may benefit from surgery such as microscopic denervation of the spermatic cord. Other treatments including pelvic floor physical therapy may also be indicated in specific circumstances. Using a thoughtful and thorough approach to evaluation and treatment of CSCP, urologists can work with patients to achieve significant improvements in quality of life.

Infectious, inflammatory and 'autoimmune' male factor infertility: how do rodent models inform clinical practice?

BACKGROUND

Infection and inflammation of the reproductive tract are significant causes of male factor infertility. Ascending infections caused by sexually transmitted bacteria or urinary tract pathogens represent the most frequent aetiology of epididymo-orchitis, but viral, haematogenous dissemination is also a contributory factor. Limitations in adequate diagnosis and therapy reflect an obvious need for further understanding of human epididymal and testicular immunopathologies and their contribution to infertility. A major obstacle for advancing our knowledge is the limited access to suitable tissue samples. Similarly, the key events in the inflammatory or autoimmune pathologies affecting human male fertility are poorly amenable to close examination. Moreover, the disease processes generally have occurred long before the patient attends the clinic for fertility assessment. In this regard, data obtained from experimental animal models and respective comparative analyses have shown promise to overcome these restrictions in humans.

OBJECTIVE AND RATIONALE

This narrative review will focus on male fertility disturbances caused by infection and inflammation, and the usefulness of the most frequently applied animal models to study these conditions.

SEARCH METHODS

An extensive search in Medline database was performed without restrictions until January 2018 using the following search terms: 'infection' and/or 'inflammation' and 'testis' and/or 'epididymis', 'infection' and/or 'inflammation' and 'male genital tract', 'male infertility', 'orchitis', 'epididymitis', 'experimental autoimmune' and 'orchitis' or 'epididymitis' or 'epididymo-orchitis', antisperm antibodies', 'vasectomy'. In addition to that, reference lists of primary and review articles were reviewed for additional publications independently by each author. Selected articles were verified by each two separate authors and discrepancies discussed within the team.

OUTCOMES

There is clear evidence that models mimicking testicular and/or epididymal inflammation and infection have been instructive in a better understanding of the mechanisms of disease initiation and progression. In this regard, rodent models of acute bacterial epididymitis best reflect the clinical situation in terms of mimicking the infection pathway, pathogens selected and the damage, such as fibrotic transformation, observed. Similarly, animal models of acute testicular and epididymal inflammation using lipopolysaccharides show impairment of reproduction, endocrine function and histological tissue architecture, also seen in men. Autoimmune responses can be studied in models of experimental autoimmune orchitis (EAO) and vasectomy. In particular, the early stages of EAO development showing inflammatory responses in the form of peritubular lymphocytic infiltrates, thickening of the lamina propria of affected tubules, production of autoantibodies against testicular antigens or secretion of pro-inflammatory mediators, replicate observations in testicular sperm extraction samples of patients with 'mixed atrophy' of spermatogenesis. Vasectomy, in the form of sperm antibodies and chronic inflammation, can also be studied in animal models, providing valuable insights into the human response.

WIDER IMPLICATIONS

This is the first comprehensive review of rodent models of both infectious and autoimmune disease of testis/epididymis, and their clinical implications, i.e. their importance in understanding male infertility related to infectious and non-infectious/autoimmune disease of the reproductive organs.

Perspective in Pediatric Pathology, Chapter 24. Testicular Inflammatory Processes in Pediatric Patients

Acute scrotal pain in children represents a major diagnostic and therapeutic challenge. An important initial differentiation should be made between epididymitis and other processes that cause acute scrotal pain, such as testicular torsion and tumor. Infectious agents disseminating through the blood flow can damage the testis by causing orchitis. On the other hand, infections ascending via spermatic pathways typically lead to epididymitis [ 1 ].

[Infection and infertility]

BACKGROUND

Infections in the urogenital tract are accepted causes of male infertility. Epidemiologic data indicate 6-10 % of all males undergoing andrological work-up for infertility having an infectious etiology.

TOPICS

This review gives a comprehensive overview on the most important urogenital tract infections (prostatitis, epididymitis, orchitis, male accessory gland infection-MAGI) and the impact on fertility. In males suffering infertility, evidence is also presented regarding an infectious etiology.

Distribution of Epididymal Involvement in Mumps Epididymo-orchitis

OBJECTIVES

To evaluate characteristic sonographic findings for mumps orchitis with epididymal involvement.

METHODS

This study included 18 patients (aged 12-18 years) with mumps orchitis. We assessed the volume, echogenicity, and vascularity of the testes and the transverse diameter, echogenicity, and vascularity of the epididymal head, body, and tail. We classified 4 types of epididymal involvement: 1A, focal swelling of the epididymal head with hypervascularity only on the swollen head; 1B, focal swelling of the epididymal head with hypervascularity on the entire epididymis; 1C, diffuse swelling of the entire epididymis with hypervascularity; and 2, no epididymal involvement. The Student t test was used to evaluate the significance of the size of each part of the epididymis and the epididymal head-to-tail diameter ratio.

RESULTS

Orchitis was unilateral in 13 patients and bilateral in 5. Of 23 affected hemiscrotums, 7 (30.4%) were type 1A, 4 (17.4%) type 1B, 2 (8.7%) type 1C, and 10 (43.5%) type 2. In 11 patients with unilateral epididymal involvement, the mean diameters ± SDs of the epididymal heads on the affected and contralateral sides were 1.11 ± 0.19 (range, 0.7-1.7) and 0.65 ± 0.14 (0.3-0.9) cm (significantly different, P <.001). The diameters of the epididymal tails on the affected and contralateral sides were 0.51 ± 0.41 (0.2-0.8) and 0.46 ± 0.21 (0.3-0.6) cm (not statistically different, P = .106). The mean head-to-tail ratios on the affected and contralateral sides were 2.28 ± 0.49 (1.29-3.00) and 1.41 ± 0.22 (1.00-1.75; significantly different, P < .001). In all types 1A and 1B, the ratio was higher than 2.00; in 22 of 23 unaffected epididymides, the ratio was lower than 2.00.

CONCLUSIONS

Focal swelling of epididymal heads was a characteristic sonographic finding of mumps epididymo-orchitis, and a head-to-tail ratio higher than 2.00 can be a useful diagnostic finding.

Outbreaks of mumps: an observational study over two decades in a single hospital in Korea

Purpose

The introduction of the mumps vaccine has dramatically reduced the number of mumps cases, but outbreaks have recently occurred among highly vaccinated populations in developed countries. Epidemiological and clinical characteristics of patients with mumps admitted between 1989 and 2012 in a single hospital in Korea are described in the present study.

Methods

We retrospectively evaluated inpatients with mumps between 1989 and 2012 and outpatients and inpatients with mumps in 2011-2012.

Results

A total of 152 patients with mumps were admitted between 1989 and 2012, and 163 patients were recorded in 2011-2012. The highest number of admitted cases occurred in 1998 and 2012 (35 and 34 cases, respectively). Among the patients admitted in 2011-2012, the highest frequency was observed among people aged 15-19 years, and low frequency was observed in those aged <4 years and >20 years, compatible to the city data and national data. In patients admitted to our department in 1998 (35 cases) and in 2010-2012 (27 cases), there were significant differences in the mean age and the rate of secondary measles-mumps-rubella (MMR) vaccination, but had similar clinical features, including complications, except aseptic meningitis. Antimumps immunoglobulin (Ig) G was positive in 83% and 100%, and IgM was positive in 67% and 41%, respectively, in the two periods.

Conclusion

In Korea, recent mumps outbreaks have occurred mainly among secondary school students who received two doses of the MMR vaccine. The vaccinees might have a modified immune reaction to viral insults, manifesting modified epidemiological and clinical features.