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Acute Flaccid paralysis

  1. A case of AFP is defined as any child aged < 15 years who has acute onset (< 4 weeks) of flaccid paralysis for which no obvious cause such as severe trauma or electrolyte imbalance is found or paralytic illness in a person of any age in which polio is suspected
  2. Anatomically AFP can be classified into 4 groups based on four level of motor unit namely muscle, neuromuscular junction, muscle fiber and anterior horn cells localization of disorder in motor unit can be done on the basis of clinical features  

AFP surveillance

  1. Surveillance is carried out for all cases of AFP and not just for poliomyelitis. Therefore all AFP cases should be reported, regardless of the final diagnosis
  2. Therefore AFP surveillance must focus on children age < 15 year, it must be flexible to capture the occasional cases that may occur in older children or adults  

Stool sample

  1. Two stool specimens should be collected at an interval of 24 to 48 hours apart and within 14 days of onset of paralysis
  2. The specimen should be placed in a clean container such as a wide mouth plastic or glass bottle with screw on cap
  3. At least one thumb sized i.e. 8 gm of stool should be collected

 

Cases of AFP are classified as polio if

 

- Wild poliovirus was isolated from any stool specimen

 

Cases of AFP without isolation of wild poliovirus may be classified as polio compatible if

 

- Stool specimens were inadequate

            And

- Residual weakness was present 60 days after onset of paralysis or 60 day follow up was not done (due to death or absence)

            And

- Expert review conducts that these cases could not be discarded as non – polio based on available data.

 

Clinical features of conditions causing acute flaccid paralysis

Site

Clinical features

Conditions

Muscle

Neck, limb girdle, proximal muscles affected Possible cardiomyopathy

Occasional respiratory muscle involvement

Myoglobinuria myopathy, hypokalemic paralysis, toxic paralysis, myopathy of intensive care

Neuromuscular junction

Cranial, limb girdle and proximal muscles May affect respiratory muscles

Autonomic signs (presynaptic)

Fatigability (post synaptic)

Myasthenia gravis

Botulism, hypermagnesemia

Peripheral nerve

Weakness: distal, symmetrical, sensory

May have associated autonomic signs

May involve cranial nerves

Deep tendon reflexes reduced/lost early

Guillain-Barre syndrome

Diphtheric neuropathy

Porphyria, lead neuropathy

Anterior horn cells

Predominantly motor signs, hyporeflexia Sensory symptoms uncommon

Often asymmetric

Hypophosphatemia, cobalamin deficiency

Poliomyelitis

Other enteroviruses

 

Differential of Acute Flaccid Paralysis
 

Signs of symptoms

Poliomyelitis

Guillain Barre syndrome

Transverse myelitis

Traumatic neuritis

Progression of paralysis

24-28 hours onset to full paralysis

From hours to 10 days

From hours to 4 days

From hours to 4 days

Fever onset

High, always present at onset of flaccid paralysis, gone the following day

Not common

Rarely present

Commonly present before, during and after flaccid paralysis

Flaccidity

Acute, asymmetrical, proximal

Acute, symmetrical, distal

Acute, lower limbs, symmetrical

Acute, asymmetric limb

Muscle tone

Diminished

Diminished

Diminished in lower limbs

Diminished in limb

Deep tendon reflexes

Decreased or absent

Absent

Absent early, hyper reflexia late

Decreased or absent

Sensation

Severe myalgia and backache, no sensory changes

Cramps, tingling, hypoanesthesia of palms and soles

Anesthesia of lower limbs with sensory level

Pain in gluteal region

Cranial nerve

Only when bulbar and bulbospinal

Often present, affecting Nerves VII, IX, X, XI, XII

Absent

Absent

Respiratory insufficiency

Only when bulbar and bulbospinal

In severe cases

Sometimes

Absent

CSF: WBCs

High WBC

< 10 WBCs

Normal

Normal

Protein

Normal or slightly increased

High

Normal or slightly elevated

Normal

Bladder dysfunction

Absent

Transient

Present

Never

Nerve conduction velocity: third week

 Abnormal, anterior horn cell disease (normal during the first two weeks)

Abnormal, demyelination

Normal or abnormal, no diagnostic value

Abnormal in sciatic nerve

EMG: 3 weeks

Abnormal

Normal

Normal

Normal

Sequelate at 3 months and up to a year

Severe, asymmetrical atrophy, skeletal deformities developing later

Symmetrical atrophy of distal muscles

Flaccid diplegia atrophy after year

Moderate atrophy, only in affected lower limb





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