2. Poliomyelitis Dept. Of Infectious Disease 2nd Affiliated Hospital CMU

3. Definition  Poliomyelitis is acute infectious disease caused by poliovirus.  Infantile paralysis.  Pathologic lesions: motor neurons in the gray matter in the anterior horn of the spinal cord..  Clinical feature:

4. Definition  Clinical feature: fever  sore throat  muscle pain  paralysis

5. Etiology  Causative agent: poliovirus  family Picornaviridae, genus Enterovirus  single strain RNA  Resistance: Sensitive to heat, oxidant  ultraviolet rays

6. Etiology  Serotype:  on the basis of neutralization tests.  Type I  Type II  Type III  no cross immunity

7. Epidemiology  Source of infection patients and carriers: inapparent inf. & non-paralytic inf.  Route of transmission air-borne, respiratory tract: fecal-oral route:

8. Epidemiology  Susceptibility:  universal susceptible to polio  covert infection >90%  paralytic patients<1%  lifelong immunity to same type virus  Epidemiologic features  children under 5yrs, 6m~5yrs  summer & fall

9. Pathogenesis

10. poliovirus oralair epithelial cells (in pharynx, intestine) first viremia second viremia non-paralytic type regional lymphatics CNS Ab covert infection Ab blood stream blood-brain barrier abortive infection paralytic type

11. Pathology  Place of lesion:  all of CNS  spinal cord, brain stem  motor neurons in anterior horns of cervical & lumbar enlargement of spinal cord.

12. Pathology  Pathologic features  neuron necrosis  inflammatory infiltrate of leukocyte,lymphocyte.

13. Clinical manifestation  Incubation period: 5~14 days  Clinical types  Covert infection: >90%  Abortive poliomyelitis: 4~8%  Non-paralytic poliomyelitis:  Paralytic poliomyelitis: 1%~2%

14. Clinical manifestation  Paralytic poliomyelitis  Prodromal period  preparalytic period  paralytic period  convalescent period  sequela period

15. Clinical manifestation Prodromal period:(1~4d)  upper respiratory tact infection:  fever, fatigue, sore throat, headache  intestinal tract infection:  vomiting, diarrhea, constipation  abortive poliomyelitis

16. Clinical manifestation  Preparalytic period  progressing this phase without prodromal phase  1~6days after symptoms of prodromal phase  without prodromal phase

17. Clinical manifestation  Preparalytic period  fever: two-hump fever(10~30%)  symptoms & signs of CNS  severe headache & vomiting  dysphoria or lethargy  muscle pain

18. Clinical manifestation  Preparalytic period  symptoms & signs of CNS  cutaneous hyperesthesia  hyperhidrosis  meningeal irritations (neck stiffness Kernigs & Brudzinskis signs positive) 3~6d, nonparalytic poliomyelitis

19. Clinical manifestation  Paralytic period  paralysis types  spinal type  brain stem type  mixed type  brain type

20. Clinical manifestation  Paralytic period  Spinal type: most common  paralysis features :  flaccid (hypomyotonia,tendon reflexes are weak or absent)  asymmetric distribution:  without sensory loss

21. Clinical manifestation  Paralytic period  Spinal type: most common  paralysis muscles  paralysis of extremities: leg >arm; proximal > distal  paralysis of diaphragmatic & intercostal muscles affects respiratory movement  paralysis of abdominal muscle -- stubborn constipation

22. Clinical manifestation  Paralytic period  Brain stem type  cranial nerve paralysis: 7&10, then 9&12,  facial paresis  dysphagia, high-pitched voice  respiratory center paralysis:  central respiratory failure:  cacorhythmic breathing ect.  vasomotor center paralysis:

23. Clinical manifestation  Paralytic period  brain type - polio-encephalitis  high fever, convulsion,  disturbance of consciousness,  tonic paralysis  mixed type  spinal type + brain stem type

24. Clinical manifestation  Convalescent period  paralytic muscles begin to recover  distal > proximal,  at first 3~4 month quick recovery, 6 month later recovery slowly,the recovery process reaches its limit around 18 months

25. Clinical manifestation  Sequela period  persistent paralysis  muscular atrophies  deformities of limbs

26. Laboratory Findings  Cerebrospinal fluid  aseptic menigitis  pleocytosis: 50~500×10 9 /L  protein: normal or slightly increase  albuminocytologic dissociation  glucose and chloride; normal  virus isolation: pharynx, feces, blood or CSF,brain.

27. Laboratory Findings  Serological test:  Specific IgM Ab (blood & CSF)  Neutralized Ab  Complement combining Ab  four fold rise

28. Diagnosis  Epidemiological data:  Clinical manifestation:  Laboratory findings:  Abortive or non-paralytic polio - isolation of virus or serological test  paralytic polio - clinical diagnosis

29. Differential Diagnosis  Guillain-Barre Syndrome  symmetric, ascending paralysis with loss  of sensation  CSF: protein elevate with absent or  minimal pleocytosis,  albuminocytologic dissociation  rapid and complete recovery  Coxsackie or ECHO: no epidemic no seqela

30. Differential Diagnosis  Paralysis caused by other enterovirus  Coxsackie or ECHO viruses:  no epidemic no sequelae

31. Treatment  Prodromal & preparalytic P  isolation & rest in bed:  not accept muscular injection & operation  hot moist pack to muscles  50%GS&VitC 1~2g iv, IFN  hydrocortison

32. Treatment  Paralytic period:  limb paralysis  nursing for paralytic limbs  Put the limbs on function position  Vit C ATP ivdrop  Galanthamin or Prostipmin iM

33. Treatment  treatment for respiratory obstacle  bulbar paralysis  dysphgia  keep air way clear (sputum aspiration postural drainage )  tracheal intubation  tracheotomy tank respirator

34. Treatment  treatment for respiratory obstacle  respiratory center paralysis  respiratory stimulant  tracheotomy tank respirator  respiratory muscle paralysis  mild observation  tank respirator

35. Treatment  Convalescent & sequela period  acupuncture  massage

36. Prevention  control of source of infection:  isolation: 40 days after the onset of illness  protection of susceptible population :  attenuated live vaccine by oral  killed virus vaccine