Mumps orchitis among soldiers: frequency, effect on sperm quality, and sperm antibodies

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.

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.

[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.

Molecular biology, pathogenesis and pathology of mumps virus

Mumps is caused by the mumps virus (MuV), a member of the Paramyxoviridae family of enveloped, non-segmented, negative-sense RNA viruses. Mumps is characterized by painful inflammatory symptoms, such as parotitis and orchitis. The virus is highly neurotropic, with laboratory evidence of central nervous system (CNS) infection in approximately half of cases. Symptomatic CNS infection occurs less frequently; nonetheless, prior to the introduction of routine vaccination, MuV was a leading cause of aseptic meningitis and viral encephalitis in many developed countries. Despite being one of the oldest recognized diseases, with a worldwide distribution, surprisingly little attention has been given to its study. Cases of aseptic meningitis associated with some vaccine strains and a global resurgence of cases, including in highly vaccinated populations, has renewed interest in the virus, particularly in its pathogenesis and the need for development of clinically relevant models of disease. In this review we summarize the current state of knowledge on the virus, its pathogenesis and its clinical and pathological outcomes.

Complicated mumps viral infection: an unusual presentation affecting only submandibular gland

This case is a single submandibular gland mumps viral infection patient without parotid gland involvement who developed complications of meningitis and orchitis. Since spontaneous remission is common in mumps viral infection, missing opportunities for exact diagnosis is frequent. As in this case, single submandibular glands infection without parotid gland involvement not only delays diagnosis but also increases risk of developing complications. This case instructs us that despite the atypical manifestation, the clinician should suspect mumps and conduct serologic tests for diagnosis while observing for complications such as meningoencephalitis and orchitis.

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

Purpose

Although the measles-mumps-rubella vaccination covers most children against mumps in Korea, the development of mumps has been reported. However, the clinical manifestations of mumps orchitis in postpubertal vaccinated patients have never been investigated. Herein we report the clinical features of mumps orchitis in postpubertal vaccinated patients.

Materials and Methods

This study included a total of 62 postpubertal males who developed acute mumps orchitis from 2005 to 2010. The clinical manifestations such as the incubation period, febrile duration, and the mean duration of orchitis were retrospectively investigated. The laboratory and sonographic findings were also reviewed and compared with the features of previously reported cases of unvaccinated postpubertal mumps orchitis.

Results

The mean age of the 62 patients was 17.56 years (range, 15 to 29 years). All patients were serologically confirmed with acute mumps infection (positive immunoglobulin [Ig] M and negative or positive IgG). The mean incubation period was 5.39 days (range, 0 to 23 days), with a febrile duration of 1.8 days (range, 0.5 to 3 days), and a mean duration of orchitis of 4.96 days (range, 0 to 17 days). Sonography revealed unilateral orchitis in 58 patients (93.6%) and bilateral orchitis in only 6 (6.4%).

Conclusions

In our study, mumps orchitis in postpubertal vaccinated patients showed a relatively shorter febrile duration. In addition, less scrotal swelling and a lower incidence of bilaterality were found upon physical examination and ultrasonography. In the future, additional long-term follow-up is needed to determine the features of mumps orchitis in postpubertal vaccinated males, and an additional booster vaccination should be considered.

Mumps orchitis in the post-vaccine era (1967-2009): a single-center series of 67 patients and review of clinical outcome and trends

Since the introduction of the mumps vaccine, the age of appearance of mumps infection has shifted from children to adolescents and young adults, groups with a higher incidence of disease complications and sequelae. During the years 2000-2001, the Gran Canaria Island was part of an epidemic of mumps. In that period, our institution attended 67 cases of serologically confirmed acute mumps orchitis, the most serious complication of mumps infection in young postpubertal males. We conducted a descriptive and prospective study of this cohort and extensively reviewed the literature from 1967 (the year the first mumps vaccine was introduced) to 2009. Fifty-six patients were admitted because of general impairment and were treated with alpha-interferon. Sixty-six patients presented parotitis previous to orchitis (interval from parotitis to orchitis, 4.9 d). Orchitis was unilateral in 89.5% and bilateral in 10.4% of cases. More than 98% of patients had orchitis-associated fever. Nine patients had clinical and biochemical data showing acute mumps meningitis, and 11 had subclinical pancreatitis. The mean duration of symptoms was 4.6 days (range, 1-9). During the acute phase, more than 41% of the evaluated testes had a volume >25 mL. Acute hormonal disturbances were highly prevalent. These included decreased levels of testosterone and inhibin B with low or normal levels of gonadotropins in 35% of subjects, and, to our knowledge not previously reported, an atypical hormonal pattern consisting of low levels of free testosterone and inhibin B, along with increased measures of luteinizing hormone but low or normal follicle-stimulating hormone levels (11% of cases). During the follow-up period (mean, 331 d) a high incidence of sperm disturbance was found.

In vitro and in vivo studies evaluating antisemen antibodies as a potential spermicidal agent in hamsters

OBJECTIVE

To determine the spermicidal activity of antisemen antibodies in the hamster model.

DESIGN

Prospective, controlled study.

SETTING

Advanced preclinical sciences center.

ANIMAL(S)

Subgroups of 10 and 14 golden hamsters.

INTERVENTION(S)

Ex vitro and in vivo treatment of sperm with antisemen antibodies or normal rabbit serum.

MAIN OUTCOME MEASURE(S)

The EC(50) value of antisemen antibodies, the time required for 50% motility loss of progressively motile spermatozoa exposed to antisemen antibodies, the average sperm mitochondrion fluorescence intensity, the rate of fertilization, and the scoring of histologic changes in the hamster vaginal tissue.

RESULT(S)

The EC(50) value of antisemen antibodies was found 70 microg/mL, and the time required for 50% motility loss of progressively motile spermatozoa exposed to antisemen antibodies (at 70 microg/mL) was 5 minutes; for the experimental and control groups, the average fluorescence intensities of sperm mitochondria were respectively 180.28 +/- 82.24 and 309.74 +/- 148.37, the fertilization rates in vitro were 0.09% and 45%, the rates of fertilization with intrauterine sperm injection were 0 and 15.0%. There was a significant difference between two groups. None of the four hamsters that received antisemen antibodies in gel-polyoxyl-40-stearate had epithelial disruption characteristic of inflammation.

CONCLUSION(S)

Antisemen antibodies possess appreciable spermicidal potential, which may be explored as an effective constituent of spermicide.

Incidence of antisperm antibodies in males with systemic autoimmune diseases

PROBLEM

To investigate if systemic autoimmune diseases could be one of the risk factors for developing antisperm antibodies (ASA) in males.

METHOD OF STUDY

Antisperm antibodies in the sera of 70 males with systemic autoimmune diseases and 80 healthy controls were examined, by using the indirect-immunobead test (I-IBT). The sperm immobilization test (SIT) was also performed to detect sperm immobilizing antibodies to the patients who were positive in I-IBT.

RESULTS

Among 70 males with systemic autoimmune diseases, five were I-IBT positives, with incidence of 7.1%. However, no positives existed in 80 healthy males. Compared with the healthy controls, the incidence of ASA in males with systemic autoimmune diseases was significantly higher (P = 0.020). None of these five ASA-positive patients had sperm immobilizing antibodies.

CONCLUSION

The incidence of ASA in males with systemic autoimmune diseases was significantly higher than in the healthy controls. Systemic autoimmune diseases may be one of the risk factors for developing ASA in men.

Serum sperm antibodies unrelated to mumps orchitis

In order to determine whether there is an association between mumps orchitis and serum sperm antibodies, we tested patients at the time orchitis was diagnosed (n = 7) and individuals who had had orchitis at least 1 month previously (n = 14). Data were compared with the results for a control group of blood donors (n = 20). Sperm antibodies were detected by the gelatin agglutination test of Kibrick, the tray agglutination test of Friberg and the ELISA. Clinically significant sperm antibody levels were not found in patients in the early stages of the disease. Four subjects tested post-disease were positive in the Friberg test and one was positive in the ELISA. One control serum was also positive in the latter test. Significant differences were not found between levels in patients in the early stages of the disease and levels in individuals post-disease, although the results of the Friberg test differed significantly between controls and former mumps orchitis cases. These data do not support the assumption of an involvement of humoral immunity against spermatozoa in mumps orchitis patients.

Mumps outbreak in a highly vaccinated school population: assessment of secondary vaccine failure using IgG avidity measurements

From March to April 2006, an outbreak of mumps occurred in Gyeonggi, Korea. The aim of this study was to describe and discriminate between primary and secondary vaccine failure in a highly vaccinated population for mumps using IgG avidity testing. Fifteen clinical mumps cases occurred among 41 students. Among these 15 patients, 11 vaccinated patients were considered secondary vaccine failures with high IgG titers and a high avidity index (AI, > or =32%); an unvaccinated patient was considered to have primary infection with high IgG titers and low AI, and three vaccinated patients were considered as other infections with low IgG titers and low AI. Among 26 unaffected students, 5 vaccinated patients were retrospectively diagnosed as sub-clinical infection with high IgG titers and high AI; the remaining students had low IgG titers and low AI except for one previously infected student. The results of this study show that secondary vaccine failure played an important role in this mumps outbreak. Therefore, booster immunization for mumps should be considered in immunized adolescents to prevent further outbreaks.

Mumps orchitis in the non-immune postpubertal male: a resurgent threat to male fertility?

OBJECTIVE

To report clinical findings associated with an increased incidence of mumps orchitis in Liverpool, UK, as in the last 2 years there has been a four-fold increase in the number of notified viral mumps cases in the UK.

PATIENTS AND METHODS

In the 8 months before April 2005, patients presenting to the Accident and Emergency/Urology Departments of the Royal Liverpool University Hospital with a diagnosis of epididymo-orchitis were identified from the emergency urological admission database.

RESULTS

Of 195 males presenting with an acute history of testicular pain and swelling, 25 gave a history of mumps parotitis 4-11 days earlier. Three had bilateral orchitis and two needed scrotal exploration to exclude torsion. Scrotal ultrasonography findings varied from increased vascularity to abnormal testicular echo texture. Treatment included analgesia, scrotal support, re-hydration and broad-spectrum antibiotics. Of the 10 patients followed-up to date, four had testicular abnormalities; one had persistent testicular pain, one a change in testicular consistency, one a noticeably reduced size of one testis, and one significant testicular atrophy.

CONCLUSION

As postpubertal mumps in males is associated with a 40% incidence of orchitis, parents should be made aware that failing to immunize their children threatens the future fertility of their sons. Young men not immunized as children should be counselled and offered urgent vaccination. Clinicians should be aware that epididymo-orchitis may be secondary to mumps infection even with no history or clinical evidence of parotitis.

Detection of secondary mumps vaccine failure by means of avidity testing for specific immunoglobulin G

The aim of this study was to discriminate between primary and secondary vaccine failure in children with mumps using IgG avidity testing. Thirty-nine serum samples from children with mumps, confirmed by specific IgM, were studied. The patients were grouped according to their immunization status. The secondary immune response was defined by IgG with an avidity index >32%. A secondary response in infected children previously immunized was considered as a secondary vaccine failure. Vaccinated children presented higher IgG titers and IgG avidity than unvaccinated children. The proportion of secondary immune responses in unvaccinated patients was lower than that obtained in previously vaccinated infected patients. Avidity testing can be a useful tool to detect secondary vaccine failure in mumps.

Diagnosis and treatment of immunologically infertile males with antisperm antibodies

The presence of antisperm antibodies (ASA) can reduce fecundity in both males and females. The present review describes a strategy, established by investigations of the diverse inhibitory effects of ASA on fertility, for the appropriate diagnosis and treatment of infertile males with ASA. For infertile males with ASA, diagnosis using the direct-immunobead test (D-IBT), the postcoital test (PCT) and the hemizona assay (HZA) should be carried out as the basis for decision-making. If the patient with ASA has an abnormal hemizona index, it seems reasonable to advise selecting intracytoplasmic sperm injection-embryo transfer (ICSI-ET) as a primary treatment. However, it has been shown that some immunologically infertile males with normal fertilizing ability established pregnancy by timed intercourse (TI) or intrauterine insemination (IUI). In such patients with ASA having normal hemizona index, TI or IUI can be selected based on the PCT result. Therefore, the treatment strategy for males with ASA is similar to that for infertile males with oligozoospermia or asthenozoospermia. In conclusion, it should be emphasized that a diversity of ASA exists and their effects on fertility in infertile males. Although there is an argument that routine testing for ASA in males is not always necessary, one should be aware that in some cases of failed IUI or IVF, ICSI is selected afterward because of the diagnosis of ASA. (Reprod Med Biol 2005; 4: 133-141).

Diversity of antisperm antibodies bound to sperm surface in male immunological infertility

PROBLEM

The presence of antisperm antibodies (ASA) in males can reduce fecundity, however, relationship between the two is disputed. This study was performed to investigate if there is diversity of ASA bound to sperm surface using immunobead test (IBT) combined with complement dependent sperm immobilization test (SIT).

METHODS

The ASA bound to sperm surface were detected using the direct IBT (D-IBT) in 275 semen samples. In some cases with ASA detected by D-IBT, sperm immobilizing antibodies bound to sperm surface were also evaluated using direct SIT (D-SIT).

RESULTS

The incidence of the immunoglobulin G (IgG), IgA, and IgM classes of ASA detected by D-IBT were 2.5, 1.8, and 0.4%, respectively. Totally, nine (3.3%) infertile men had ASA on the sperm surface. D-SIT was tested positive in four (66.7%) of six cases with ASA assessed by D-IBT.

CONCLUSIONS

Some of the sperm-bound antibodies are associated with complement dependent sperm immobilizing antibodies, indicating that there exists a heterogeneity of sperm-bound antibodies. This result might be one of the reasons for the controversy about the relationship between ASA and immunological infertility in men.

Serum sperm antibodies are not elevated after mumps orchitis

OBJECTIVE

To assess the level of serum sperm antibodies after mumps orchitis.

DESIGN

Controlled descriptive study.

SETTING

Academic research environment.

PATIENT(S)

Seventy-four mumps orchitis patients.

INTERVENTION(S)

Sampling of serum at different intervals after the onset of orchitis symptoms: 1 to 7 days, 31 to 60 days, and 61 to 431 days.

MAIN OUTCOME MEASURE(S)

Level of serum sperm antibodies, using Kibrick's gelatin agglutination test, Friberg's tray agglutination test, Isojima's sperm immobilization test, and ELISA.

RESULT(S)

Clinically relevant sperm antibody values were detected by the Friberg method among patients tested from 1 to 7 days (10.5%) and 61 to 431 days (10.5%) after the onset of disease. The Isojima test revealed a statistically insignificant higher incidence among patients at 61 to 431 days (31.6%) as compared with those sampled at 1 to 7 days (10.5%). None of the orchitis sera tested positive by the Kibrick and ELISA techniques. The established incidences did not differ significantly from the results for negative controls (blood donors) and were lower than the values acquired from positive controls (males with unexplained infertility).

CONCLUSION(S)

Mumps orchitis does not cause enhanced humoral immunity to spermatozoa.

The preventive effect of systemic treatment with interferon-alpha2B for infertility from mumps orchitis

OBJECTIVE

To evaluate the effect of interferon-alpha2B on mumps orchitis, often caused by postpubertal mumps and which can result in permanent testicular atrophy.

PATIENTS AND METHODS

The study included 21 patients with mumps orchitis, treated between May 1990 and June 1997. Patients were randomly assigned into two groups: in group 1, 13 patients received therapy with interferon-alpha2B (3 x 10(6) IU per day) and group 2 did not, acting as controls. All were evaluated by measurements of testis size, mumps virus titre, hormone level and semen analysis.

RESULTS

In group 1, the patients' symptoms resolved within 2-3 days and the volume of the testes returned to normal within 11 days; there was no testicular atrophy in any patient during the follow-up. However, asthenospermia continued to be detected in four patients (unilateral in two, bilateral in two). In group 2, the patients' symptoms resolved within 5-6 days and the volume of the testes returned to normal within 10 days; testes atrophied in three patients (unilateral in two, bilateral in one) during the follow-up. Asthenospermia continued in four patients (unilateral in two, bilateral in two).

CONCLUSION

These results suggest that treatment with systemic interferon-alpha2B is effective in preventing testicular atrophy when combined with standard symptomatic treatment.

Acute scrotal pain

The diagnosis of acute scrotal pain can be difficult. The most common causes include torsion of a testicular appendage, epididymitis, and testicular torsion, which account for 85% to 90% of all cases. These entities may be clinically indistinguishable because characteristic symptoms and signs for each overlap, whereas pathognomonic features are uncommon. Diagnostic accuracy without delay is required to avoid the loss of testicular function in testicular torsion cases and to avoid unnecessary surgery in other cases. A thorough understanding of the key clinical features of each entity, coupled with an understanding of the appropriate use of perfusion imaging studies, will equip the emergency physician with the tools to accomplish this task.

Mumps orchitis: report of a mini-epidemic

PURPOSE

The incidence of mumps orchitis has declined dramatically since the introduction of vaccination. While in the past cases of mumps have only been seen occasionally at our institution, recently there has been a sharp increase in the number of confirmed cases.

MATERIALS AND METHODS

Between June 1995 and April 1996, 11 patients with severe mumps orchitis were hospitalized at our clinic. Medical history, therapeutic measures and clinical outcome were recorded for each patient.

RESULTS

All patients showed marked scrotal swelling with a temperature above 38.5 C. Serum C-reactive protein was significantly elevated (mean 140 mg./l.). The vaccination status of 1 of the 11 patients (9%) was unknown. Medical records from the remaining 10 patients indicated that they had not been vaccinated. Nine patients (82%) had a typical mumps parotitis preceding the orchitis. In 2 patients the clinical diagnosis of parotitis was uncertain but mumps serology was positive. None of the patients showed other manifestations of mumps. Antibodies to the mumps virus (IgG and IgM) were determined in 6 patients and positive in all cases. The average interval between parotitis and onset of orchitis was 10 days. All patients were hospitalized for an average of 6 days. Treatment included bed rest with local cooling, scrotal support and systemic treatment with nonsteroidal anti-inflammatory drugs. Ciprofloxacin or clavulanic acid/amoxicillin was administered as bacterial orchitis could not be excluded at initial presentation. The mean time to cessation of fever was 3.6 days (range 3 to 5). Antibiotics were administered for an average of 8.8 days (range 7 to 13) and anti-inflammatory drugs were given an average of 8.6 days (range 7 to 11). One patient required scrotal exploration.

CONCLUSIONS

Since the introduction of a vaccine against the mumps virus there is a diminished risk for mumps and its complications. However, in case of scrotal swelling mumps orchitis should still be considered. Despite vaccination mumps has not been erradicated. Therefore, continued vaccination should be considered an important step in minimizing clinical outbreaks and working towards a possible eradication of this disease in the future.