1. Name:Nurzawani Binti Shamsudin Matric No: 0918424 POLIOMYELITIS

2. Definition Acute enteroviral illness with prodorme vomiting and fever associated with an aseptic meningitis picture during which the patient experiences the evolution of an asymmetrical flaccid weakness without sensory loss as groups of anterior horn cells become infected. 3. Polioviruses polioviruses are nonenveloped, positive- stranded RNA viruses belonging to the genus Enterovirus, in the Picornaviridae family 3 antigenically distinct serotypes (types 1, 2, and 3) spread from the intestinal tract to the central nervous system (CNS), where they cause aseptic meningitis and poliomyelitis, or polio can retain infectivity for 4. Epidemiology 9095% of infections are in apparent but induce protective immunity out of 5%, paralytic polio occurring in about 1/1,000 infections among infants to about 1/100 infections among adolescents in developed countries prior to universal vaccination, epidemics of paralytic poliomyelitis occurred primarily in adolescents conversely, in developing countries with poor sanitation, infection early in life results in infantile paralysis poor sanitation and crowding have permitted the continued transmission of poliovirus in certain poor countries in Africa and Asia 5. Epidemiology 6. Pathogenesis Virus ingested through mouth Multiply in Peyers patches of ileum (M cells) Go to blood stream Primary viremia (2-3 days) Multiply in reticuloendothelial system Blood stream 2 viremia then invade CNS 7. Clinical Manifestation The incubation period of poliovirus from contact to initial clinical symptoms is usually considered to be 812 days, with a range of 5 35 days. Paralysis, if it occurs, appears 38 days after the initial symptoms. 8. Abortive Poliomyelitis o In about 5% of patients, a nonspecific influenza-like syndrome occurs 12 wk after infection, which is termed abortive poliomyelitis. o Fever, malaise, anorexia, and headache are prominent features, and there may be sore throat and abdominal or muscular pain. Vomiting occurs irregularly. o The illness is short lived, up to 23 days. Recovery is complete, and no neurologic signs or sequel develop. Clinical Manifestation 9. Nonparalytic Poliomyelitis o In about 1% of patient presents with the manifestations of abortive type associated with aseptic meningitis such as neck rigidity, +ve Kernigs sign and Brudzinskis sign. o CSF shows changes of aseptic meningitis. o The manifestations disappear 1-2 days and leave no paralytic manifestations. Clinical Manifestation 10. Paralyitic Poliomyelitis o Occur in 0.5-1% of all cases, usually begins with manifestations of abortive or non paralytic poliomyelitis. o Then after 3-8 days paralytic manifest o The major symptoms, however, are due to invasion of the motor nerves, which are responsible for movement of the muscles. o This viral invasion causes inflammation, and then destruction of these nerves. o Divided into 3 types: 1. Spinal 2. Bulbar 3. Encephalitic Clinical Manifestation 11. 1. Spinal Poliomyelitis o The muscle affected are: lower limbs (quadriceps, harmstrings, anterior tibial and peroneal muscle) and upper limbs (deltiod muscle). o The muscle limbs are the most common affected ones but muscles of chest wall, diaphragm, abdominal wall, urinary bladder and bowel may affected. o The paralysis is characterized by being: Asymmetrical Patchy Non Progressive Purely motor Lower motor neuron lesion: associated with hypotonia, loss of deep reflexes and muscle wasting 12. 2. Bulbar poliomyelitis o Bulb of brain mid brain, pons and medulla contain following centers: respiratory, heat regulating centre and motor nuclei of cranial nerves. o Clinically patient will get: 1. Bradycardia 2. Irregular respiration with apnoea, cyanosis and respiratory failure 3. Cranial nerve palsy; squint, pin point pupils, dysphagia, nasal tone and nasal regurgitation of fluids 4. Hypo or Hyperthermia 13. 3. Encephalitis poliomyelitis Manifestation of encephalitis are evident. o Disturbed consciousness (from drowsiness to coma) o Convulsions o Localized manifestation as blindness, deafness and paralysis (monoplegia or hemiplegia) Diagnosis depend on: a) Presence of epidemic of polio b) Isolation of the virus from CSF c) Increase antibody titre against polio 14. Poliomyelitis Gullain Barre syndrome Botulism Peripheral neuritis Transverse myelitis Etiology Poliovirus Post infectious (immunologic) Clostridium botulinum in contaminated food Post diphtheritic Vit. B deficiency, lead posoning, DM Post infectious Onset of paralysis Acute Insidious Acute Acute Acute Fever at onset of paralysis Present Absent Absent Absent Absent Sign of meningeal irritation Present Absent Absent Absent Absent Character of paralysis LMNL (reduce tone, diminished reflex, wasting muscle, asymmetry patchy, pure motor) LMNL (bilateral and symmetric, predominantly motor) LMNL (bilateral and symmetric, pure motor) LMNL (bilateral and symmetric, motor and sensory) In lower limb Early: flaccid paralysis Late: spastic Progressive of paralysis Non Progressive Progressive in the 1st 2 weeks in an ascending manner Non Progressive Non Progressive Non Progressive Sensory changes No sensory changes Paraesthesia No sensory changes Gloves and stockings hypoesthesia Loss of sensation in lower limbs with sensory level Investigation lymphocyte proteins or protein but normal cells Normal Normal Normal 15. Investigation 1. Isolation of the virus from throat swabs, faeces and rectal swabs. It is rarely isolated from CSF. Can be readily grown and identified in cell culture. Require molecular technique. 2. Rise in antibodies in paired samples, one in acute stage and another one 2-3 weeks later. 3. CSF: Show normal or increased pressure, clear or turbid with increase cells (mainly lymphocytes), proteins (30-60mg % and later may rise to 100-600mg%) and normal glucose level. 16. Treatment Prevent disease by immunization with inactivated polio vaccine Supportive treatment aimed at limiting progression of disease Intubation/tracheostomy, bladder catheter, tube feeding may be required Post polio paralysis is mild in 30%, permanent in 15%. Physical therapy may be required Immunodeficiency and underimmunization are the major causes of paralytic polio in the worldwide today. Vaccine-associated paralytic polio has been nearly eliminated by the use of inactivated vaccine. 17. Vaccine Oral Poliovirus Vaccine (OPV) Consists of live attenuated virus of all 3 serotypes Produce local immunity through induction of an IgA response as well as systemic immunity Rarely cause paralytic poliomyelitis, around 1 in 3 million doses Much cheaper than IPV Known as Sabin vaccine 18. (Intramuscular) Inactivated Poliovirus Vaccine (IPV) Consists of formalin inactivated virus of all 3 poliovirus serotypes Produce serum Ab only; does not induce local gut immunity. Thus , do not prevent local infection of gut. It will prevent paralytic poliomyelitis since viremia is essential cause pathogenesis of the disease. Known as Salk vaccine