PoliomyelitisPoliomyelitis

ObjectivesObjectives Etiology Etiology Epidemiology Epidemiology Pathogenesis Pathogenesis Clinical manifestationsClinical manifestations Diagnosis Diagnosis Differential diagnosisDifferential diagnosis Management Management Prevention Prevention Prognosis Prognosis

VotingVoting paralysis is the most common paralysis is the most common

Y/NY/N::presentation of poliomyelitispresentation of poliomyelitis

ETIOLOGYETIOLOGY

Poliomyelitis is an acute Poliomyelitis is an acute

enteroviral illness caused by poliovirus.enteroviral illness caused by poliovirus. 3 serotypes are present: type 1, 2, 33 serotypes are present: type 1, 2, 3 The polioviruses are extremely hardy and The polioviruses are extremely hardy and

can retain infectivity for several days at room can retain infectivity for several days at room temperature.temperature.

EpidemiologyEpidemiology The most devastating result of poliovirus The most devastating result of poliovirus

infection is paralysisinfection is paralysis paralysis was more in adolescents in the paralysis was more in adolescents in the

developed countries and more in infants in the developed countries and more in infants in the developing countries (bad sanitation).developing countries (bad sanitation).

paralytic polio occurring in about 1/1,000 paralytic polio occurring in about 1/1,000 infections among infants to about 1/100 infections infections among infants to about 1/100 infections among adolescents.among adolescents.

Universal vaccination results in global eradication Universal vaccination results in global eradication by 2000 (99% decline) but continued transmission by 2000 (99% decline) but continued transmission occurs in some poor countries in Asia and Africa. occurs in some poor countries in Asia and Africa.

The number of worldwide polio cases has The number of worldwide polio cases has fallen from an estimated 350,000 in 1988 to fallen from an estimated 350,000 in 1988 to fewer than 1300 in 2010—a decline of more fewer than 1300 in 2010—a decline of more than 99% in reported cases. than 99% in reported cases.

Successful Global Polio Successful Global Polio Eradication EffortsEradication Efforts

CDC and its international partners have made CDC and its international partners have made significant progress over the past 22 years.significant progress over the past 22 years.

Three regions of the world are certified polio freeThree regions of the world are certified polio free—the Americas, Europe, and the Western Pacific. —the Americas, Europe, and the Western Pacific.

Only four polio-endemic countries (countries that Only four polio-endemic countries (countries that have never interrupted the transmission of wild have never interrupted the transmission of wild poliovirus) remain—Afghanistan, India, Nigeria, poliovirus) remain—Afghanistan, India, Nigeria, and Pakistan. and Pakistan.

PathogenesisPathogenesis Humans are the only known reservoir for the Humans are the only known reservoir for the

polioviruses, which are spread by the fecal-oral polioviruses, which are spread by the fecal-oral route. route.

Polioviruses spread from the intestinal tract to the Polioviruses spread from the intestinal tract to the CNS, where they cause aseptic meningitis and CNS, where they cause aseptic meningitis and poliomyelitis. poliomyelitis.

Poliovirus primarily infects AHC and medulla Poliovirus primarily infects AHC and medulla oblongata. oblongata.

However, poliovirus has almost never been However, poliovirus has almost never been cultured from CSF in patients with paralytic cultured from CSF in patients with paralytic diseasedisease

Clinical manifestaionsClinical manifestaions The incubation period is usually 8–12 days, The incubation period is usually 8–12 days,

(5–35 days)(5–35 days) Poliovirus infections with wild-type virus Poliovirus infections with wild-type virus

may follow 1 of several courses:may follow 1 of several courses:

1.1. inapparent infection (90–95% of cases) and inapparent infection (90–95% of cases) and causes no disease and no sequelae; causes no disease and no sequelae;

2.2. abortive poliomyelitis (5%) abortive poliomyelitis (5%)

3.3. nonparalytic poliomyelitis (1%) nonparalytic poliomyelitis (1%)

4.4. paralytic poliomyelitis (0.1%)paralytic poliomyelitis (0.1%)

Abortive PoliomyelitisAbortive Poliomyelitis nonspecific influenza-like syndrome occurs 1–2 nonspecific influenza-like syndrome occurs 1–2

wk after infection. wk after infection. Fever, malaise, anorexia, and headache are Fever, malaise, anorexia, and headache are

prominent features, and there may be sore throat prominent features, and there may be sore throat and abdominal or muscular pain and vomiting.and abdominal or muscular pain and vomiting.

The illness is short lived, up to 2–3 days. The illness is short lived, up to 2–3 days. The physical examination may be normal or may The physical examination may be normal or may

reveal nonspecific pharyngitis, abdominal or reveal nonspecific pharyngitis, abdominal or muscular tenderness, and weakness. muscular tenderness, and weakness.

Recovery is complete with no neurologic signs or Recovery is complete with no neurologic signs or sequelae develop.sequelae develop.

Nonparalytic PoliomyelitisNonparalytic Poliomyelitis more intense headache, nausea, and vomiting, as more intense headache, nausea, and vomiting, as

well as soreness and stiffness of the posterior well as soreness and stiffness of the posterior muscles of the neck, trunk, and limbs. muscles of the neck, trunk, and limbs.

Fleeting paralysis of the bladder and constipation Fleeting paralysis of the bladder and constipation are frequent. are frequent.

Approximately of these children have a short ⅔Approximately of these children have a short ⅔symptom-free interlude between the 1st phase symptom-free interlude between the 1st phase (minor illness) and the 2nd phase (CNS disease or (minor illness) and the 2nd phase (CNS disease or major illness). major illness).

Nuchal and spinal rigidity are the basis for Nuchal and spinal rigidity are the basis for the diagnosis of nonparalytic poliomyelitis the diagnosis of nonparalytic poliomyelitis during the 2nd phase.during the 2nd phase.

Reflexes are absent with onset of flaccid Reflexes are absent with onset of flaccid paralysis.paralysis.

Sensory changes don’t occur.Sensory changes don’t occur. Patients with aseptic meningitis never have Patients with aseptic meningitis never have

paralysis.paralysis.

Paralytic poliomyelitisParalytic poliomyelitis

3 clinically recognizable syndromes that 3 clinically recognizable syndromes that represent a continuum of infection represent a continuum of infection differentiated only by the portions of the differentiated only by the portions of the CNS most severely affected.CNS most severely affected.

(1)(1) spinal paralytic poliomyelitisspinal paralytic poliomyelitis

(2)(2)bulbar poliomyelitis, and bulbar poliomyelitis, and

(3)(3)polioencephalitis.polioencephalitis.

Spinal paralytic polioSpinal paralytic polio 11stst phase corresponds to the abotive polio phase corresponds to the abotive polio This may be followed by 2-5 days of apparent This may be followed by 2-5 days of apparent

normalcy then the 2normalcy then the 2ndnd phase which is characterized phase which is characterized by:by:

Severe headache and feverSevere headache and fever Motor and sensory changes: parasthesia, Motor and sensory changes: parasthesia,

hypersthesia, fasiculations, spasmhypersthesia, fasiculations, spasm Paralysis that is characteristically spotty and Paralysis that is characteristically spotty and

commonly involves one leg or one arm with more commonly involves one leg or one arm with more proximal that distal weaknessproximal that distal weakness

Bowel and bladder dysfunction are commonBowel and bladder dysfunction are common Sensation is intactSensation is intact

Bulbar paralytic polioBulbar paralytic polio

Dysfunction of the cranial nerves and Dysfunction of the cranial nerves and medullary centers are the dominant featuresmedullary centers are the dominant features

Hypertension and autonomic disturbances Hypertension and autonomic disturbances are commonare common

Associated paralysis may occur.Associated paralysis may occur.

PolioencephalitisPolioencephalitis

Higher brain centers are involvedHigher brain centers are involved Seizures, coma and spastic paralysis may Seizures, coma and spastic paralysis may

occur.occur. Irritability, disorientation, drowsiness, and Irritability, disorientation, drowsiness, and

coarse tremors are often present with coarse tremors are often present with peripheral or cranial nerve paralysis that peripheral or cranial nerve paralysis that coexists or ensues. coexists or ensues.

Hypoxia and hypercapnia due to respiratory Hypoxia and hypercapnia due to respiratory insufficiency may produce disorientation insufficiency may produce disorientation without true encephalitis.without true encephalitis.

DIAGNOSISDIAGNOSIS

Poliomyelitis should be considered in any Poliomyelitis should be considered in any unimmunized or incompletely immunized child unimmunized or incompletely immunized child with paralytic disease.with paralytic disease.

(WHO) recommends that the laboratory diagnosis (WHO) recommends that the laboratory diagnosis of poliomyelitis be confirmed by isolation and of poliomyelitis be confirmed by isolation and identification of poliovirus in the stool.identification of poliovirus in the stool.

2 stool specimens should be collected 24–48 hr 2 stool specimens should be collected 24–48 hr apart, as soon as possible after the diagnosis of apart, as soon as possible after the diagnosis of poliomyelitis is suspected (the optimal time for poliomyelitis is suspected (the optimal time for collection of stool specimens is the 1st week after collection of stool specimens is the 1st week after the onset of paralysis)the onset of paralysis)

The CSF, while often normal during the The CSF, while often normal during the minor illness, with CNS involvement minor illness, with CNS involvement demonstrates a pleocytosis of 20–300 demonstrates a pleocytosis of 20–300 cells/mmcells/mm3 3 with normal or slightly elevated with normal or slightly elevated protein during 1protein during 1stst week. However, during 2 week. However, during 2ndnd week, cells fall to normal and protein week, cells fall to normal and protein elevates up to 50-100 mg/dl.elevates up to 50-100 mg/dl.

Serologic testing demonstrates Serologic testing demonstrates seroconversion or a 4-fold or greater seroconversion or a 4-fold or greater increase in antibody titers, when measured increase in antibody titers, when measured during the acute phase of illness and 3–6 wk during the acute phase of illness and 3–6 wk later.later.

Differential diagnosisDifferential diagnosisPoliomyelitis should be considered in the Poliomyelitis should be considered in the

differential diagnosis of any case of acute differential diagnosis of any case of acute flaccid paralysisflaccid paralysis (?)(?)

Guillian-Barre syndromeGuillian-Barre syndrome Infectious : non-polio enteroviruses, west-Infectious : non-polio enteroviruses, west-

nile virus, rabies, varicella, botulism..nile virus, rabies, varicella, botulism.. Acute transverse myelitisAcute transverse myelitis Tick bite paralysisTick bite paralysis Polymyositis Polymyositis

Poliomyelitis GBSProdrome Fever, headache,

meningeal signsPreceeding infection with less notable prodrome

Progression of paralysis

within 24-48 hs Within hours- 10 days

Distribution of paralysis

asymmetric symmetric

Sensory changes absent common

Pyramidal signs absent common

DTR Reduced/absent Reduced/absent

Residual paralysis yes -/+

CSF Pleocytosis with normal or slightly elevated protein

Few cells with high protein

TreatmentTreatment

There is no specific antiviral treatment for There is no specific antiviral treatment for poliomyelitis. poliomyelitis.

The management is supportive and aimed at The management is supportive and aimed at limiting progression of disease, prevention limiting progression of disease, prevention of ensuing skeletal deformities, and of ensuing skeletal deformities, and preparation of the child and family for preparation of the child and family for prolonged treatment required and for prolonged treatment required and for permanent disability if this seems likely. permanent disability if this seems likely.

Abotive and nonparalytic polioAbotive and nonparalytic polio

Supportive management: analgesics, Supportive management: analgesics, sedatives, diet, and bed rest till fever sedatives, diet, and bed rest till fever disappears. disappears.

All intramuscular injections and surgical All intramuscular injections and surgical procedures are contraindicated during the procedures are contraindicated during the acute phase of the illness, because these acute phase of the illness, because these may result in progression of disease.may result in progression of disease.

Careful neurologic and musculoskeletal Careful neurologic and musculoskeletal examination 2 months after recovery to examination 2 months after recovery to detect minor defects.detect minor defects.

Paralytic polioParalytic polio

Complete bed rest in a calm atmosphere for Complete bed rest in a calm atmosphere for the 1the 1stst 2-3 weeks 2-3 weeks

Suppotive management is neededSuppotive management is needed Ventilatory support is usually needed for Ventilatory support is usually needed for

respiratory failurerespiratory failure

ComplicationsComplications Acute gastric dilatation may occur abruptly.Acute gastric dilatation may occur abruptly. Melena from superficial intestinal erosions; Melena from superficial intestinal erosions;

perforation is rare. perforation is rare. Mild hypertension for days or weeks is common Mild hypertension for days or weeks is common

in the acute stage. in the acute stage. In the later stages, because of immobilization, In the later stages, because of immobilization,

hypertension may occur along with hypertension may occur along with hypercalcemia, nephrocalcinosis, and vascular hypercalcemia, nephrocalcinosis, and vascular lesions. lesions.

ECG abnormalities suggesting myocarditis are ECG abnormalities suggesting myocarditis are not rare. not rare.

PREVENTIONPREVENTION

ImmunizationImmunization

Polio vaccinesPolio vaccines OPV and IPV protect against the 3 strains of OPV and IPV protect against the 3 strains of

polio polio IPV induces higher serum IgG antibodies while IPV induces higher serum IgG antibodies while

OPV induce greater mucosal IgA in the GIT.OPV induce greater mucosal IgA in the GIT. All children should receive 4 doses of IPV at All children should receive 4 doses of IPV at

2,4,6- 18 months and at 4-6 years.2,4,6- 18 months and at 4-6 years. In our country: In our country: IPV is given at 1 ,2 monthsIPV is given at 1 ,2 months OPV is given at 2, 4, 6, 18 months and at 6 years.OPV is given at 2, 4, 6, 18 months and at 6 years.

VAPPVAPP Very rare ( 1/6.2 million ) but the risk for paralysis in the Very rare ( 1/6.2 million ) but the risk for paralysis in the

immunodeficient recipient may be as much as 6,800 immunodeficient recipient may be as much as 6,800 times that in normal subjects.times that in normal subjects.

OPV is safe ( vaccine strains don’t replicate in the CNS ). OPV is safe ( vaccine strains don’t replicate in the CNS ). However, reversion in the small intestine occurs However, reversion in the small intestine occurs occasionally with access the CNS via peripheral nerves occasionally with access the CNS via peripheral nerves causing VAPP.causing VAPP.

VAPP should be considered in any child with paralytic VAPP should be considered in any child with paralytic disease occurring 7–14 days or at later times after disease occurring 7–14 days or at later times after receiving OPV in countries or regions where wild-type receiving OPV in countries or regions where wild-type poliovirus has been eradicated and the OPV has been poliovirus has been eradicated and the OPV has been administered to the child or a contact.administered to the child or a contact.

PROGNOSISPROGNOSIS

Inapparent, abortive polio and aseptic Inapparent, abortive polio and aseptic meningitis have good prognosis with no meningitis have good prognosis with no long-term sequel.long-term sequel.

Mortality rate in severe bulbar polio is as Mortality rate in severe bulbar polio is as high as 60 % and is 5- 10% in less severe high as 60 % and is 5- 10% in less severe disease.disease.

Recovery from paralysis is usually up to 6 Recovery from paralysis is usually up to 6 months after which paralysis is permanent.months after which paralysis is permanent.

Postpolio syndromePostpolio syndrome

30-40 % of of patients who survived 30-40 % of of patients who survived paralytic polio may develop exacerbation or paralytic polio may develop exacerbation or new weakness and muscle pain 30-40 years new weakness and muscle pain 30-40 years after infectionafter infection

ConclusionConclusion

poliomyelitis is acute enteroviral illness.poliomyelitis is acute enteroviral illness. The most devastating result of poliovirus The most devastating result of poliovirus

infection is paralysisinfection is paralysis Poliomyelitis should be considered in the Poliomyelitis should be considered in the

differential diagnosis of any case of differential diagnosis of any case of paralysis.paralysis.

Vaccination is the only effective method of Vaccination is the only effective method of prevention.prevention.

Thank youThank you