6. What is AFP?
a clinical syndrome characterized by
Rapid onset of weakness including
(less frequently) weakness of the
muscles of respiration & swallowing
Progressing to maximum severity
within several days to weeks
7. Sudden onset of weakness or paralysis
over a period of 15 days in a patient aged
less than 15 years age
Flaccid paralysis evolving over hours or a few
days
suggests involvement of the lower motor
neuron complex
DEFINITION
8. Anterior horn cells AHC (spinal cord)
acute poliomyelitis
acute transverse myelitis
Peripheral Nerves
roots: GBS (post-infectious)
toxins: Diphteria, porphyria
N-M junction:
botulinum toxin , tick toxin
Metabolic: Periodic paralysis
Muscular: myositis (rare)
A lesion compressing the spinal cord must be ruled out
Syndromes Presenting as AFP (DD)
9.
10. Most common
Poliomyelitis
Guillain-Barre Syndrome
Transverse myelitis
Acute Flaccid Paralysis(AFP)
Differential diagnosis
11. AFP in <15yrs age child is
notify-able disease to WHO
Polio surveillance officers—all
districts
13. Poliomyelitis
Polio= gray matter
Myelitis= inflammation of the spinal cord
Most affects children < the age of 5
Global eradication in near future
Etiology
Enterovirus (RNA)
Three serotypes: 1, 2, 3
14. Clinical Classification of Poliomyelitis
Asymptomatic infection (Inapparent) (90- 95%)
Abortive poliomyelitis (5%)
Non- paralytic poliomyelitis (aseptic meningitis) (1- 4%)
Paralytic poliomyelitis (0.1-1%)
Spinal form
Bulbar form
Bulbospinal form
Encephalitic form
Poliovirus infections may follow one of several courses
15. Paralytic poliomyelitis
Prodromal period
Preparalytic period
Paralytic period
Convalescent period
Sequela period
Commonly known as Polio
Only 1/1,000 to 1/100 (0.1% to 1%) infected
individuals develop paralytic disease
16. Preparalytic period
High fever
Cutaneous hyperesthesia or paresthesia in the
extremities
Muscular pain is common
Muscles are tender even to gentle palpation
Severe headache & vomiting
Lethargy
Signs of meningeal irritation
(neck stiffness, Kerning & Brudzinski signs positive)
Paralytic poliomyelitis
17. Weakness of one or more muscle groups (spinal or
cranial)
Loose & Floppy Limbs, hypotonia-- Flaccid paralysis
Asymmetric paralysis
Paralysis is complete – fever normalizes
Weakness persists
Respiratory & vasomotor changes
Bladder & bowel dysfunction
Tendon reflexes are absent with paralysis.
Sensory defects do not occur in poliomyelitis
Paralytic poliomyelitis
Paralytic period
18. Spinal type: most common
Paralysis of extremities (muscle groups )
leg > arm
proximal > distal
Asymmetric paralysis
Paralysis of diaphragmatic & intercostal
muscles affects respiratory movement
Paralysis of abdominal muscle -- stubborn
constipation
Paralytic poliomyelitis
19. Sequela
Poliomyelitis may lead to severe asymmetrical
persistent paralysis
muscular atrophies
deformities of limbs
Paralytic poliomyelitis
20. Diagnosis
WHO recommends diagnosis of poliomyelitis be
confirmed by isolation and identification of poliovirus in
the stool, with specific identification of wild-type and
vaccine type strains
Polioviruses may be isolated from 80 to 90% of acutely
ill patients
whereas less than 20% may yield virus within 3-4 wk
after onset of paralysis
Identification of poliovirus in stool
21. Stool examination
Two samples 24 hr apart
Within 14 days of onset of paralysis
8-10 grams or thumb size
Collected in a clean wide mouth bottle –
(plastic or glass) with screw cap
Sample stored below 8°C
No dessication or leakage till received
at WHO Accredited Lab
Collection of sample
22. Laboratory Findings
Cerebrospinal fluid
aseptic menigitis
pleocytosis: 50~500×109
/L
protein: normal or slightly increase
glucose and chloride; normal
albuminocytologic dissociation
Serological Tests
Neutralizing antibodies (IgG)
Antibodies to C antigen (IgM)
Anti-D antibodies
23. Management
Isolation
Rest in bed
Neutral positioning of the limbs
Good nursing
No I.M Injection or surgery
Relief of pain and spasm of muscles
Physiotherapy
Treatment symptomatic and supportive
24. Prevention
control of source of infection:
isolation: 40 days after the onset of illness
protection of susceptible population-
vaccination :
attenuated live vaccine by
Oral -- OPV
killed virus vaccine
Injectable -- IPV
26. Guillain-Barre Syndrome
(GBS)
Post-infectious
acute, rapidly progressing
ascending
potentially fatal form of polyneuritis
involving mainly motor but sometimes also
sensory and autonomic nerves
also known as: Acute inflammatory demyelinating
polyneuropathy (AIDP)
27.
28.
29.
30.
31. Transverse Mylitis
A neurological condition
in which the spinal cord is
inflamed.
The inflammation damages nerve fibers,
and causes them to lose their myelin
coating leading to decreased electrical
conductivity in the central nervous system.
32. 2nd most common cause of symmetric AFP
Segmental dysfunction of spinal cord
without evidence of spinal cord
compression
Cause is either:
a direct viral infection
or
an autoimmune disease
Transverse Mylitis
33. Transverse Mylitis
Paralysis usually affect only Lower Limbs
(Paraplegia)
Rare above C-5→quadriplegia
Initially flaccid but gradual change to
spasticity over few weeks
Sensory loss (with sensory level on the
trunk) and
Autonomic disturbance (urinary retention
and stool incontinence) usually present
37. Botulism
It’s a toxic neuromuscular blockade
caused by Clostridium botulinum
(anaerobic gram positive)
According to the type of infection, there
are 3 types
Infant B. due to exposure to soil , honey
Food-borne B. due to ingestion improperly
home preserved foods containing the toxins
Wound B. due to wound contamination with
the organism
38. All three types of botulism result in
symmetric
descending
Flaccid paralysis of motor and
autonomic nerves
always beginning with cranial nerves
These symptoms preceded by
constipation (infant botulism)
If untreated - paralysis of respiratory →
death
Botulism
40. Pseudoparalysis
Not a true paralysis
May follow
Unrecognized trauma
Fracture
Sprain
Toxic synovitis of hip or knee
Acute osteomylitis
Careful exam show focal tenderness
Usually painful limping gait
Neurological exam → normal
42. Trauma to the back
Spinal epidural abscess
Vascular anomalies of the cord
Spinal cord tumors
Clinically difficult to differentiate from
Transverse Mylitis
CT scan/ MRI spine:
Sensitive
Can show nature of obstruction
Acute spinal cord compression
43. Prognosis & complications of AFP
According to cause
Poliomyelitis
Respiratory
death
Limb atrophy
GBS
Respiratory
autonomic crises
residual weakness
death
Acute transverse myelitis
Residual deficits --bowel and bladder
dysfunction & weakness - lower Limbs