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Poliomyelitis Dept. Of Infectious Disease 2nd Affiliated Hospital CMU 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: Definition Clinical feature: fever sore throat muscle pain paralysis Etiology Causative agent: poliovirus family Picornaviridae, genus Enterovirus single strain RNA Resistance: Sensitive to heat, oxidant ultraviolet rays Etiology Serotype: on the basis of neutralization tests. Type I Type II Type III no cross immunity Epidemiology Source of infection patients and carriers: inapparent inf. & non-paralytic inf. Route of transmission air-borne, respiratory tract: fecal-oral route: 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 Pathogenesis poliovirus air oral epithelial cells (in pharynx, intestine) regional lymphatics Ab covert infection blood stream first viremia Ab second viremia abortive infection blood-brain barrier CNS non-paralytic type paralytic type Pathology Place of lesion: all of CNS spinal cord, brain stem motor neurons in anterior horns of cervical & lumbar enlargement of spinal cord. Pathology Pathologic features neuron necrosis inflammatory infiltrate of leukocyte,lymphocyte. Clinical manifestation Incubation period: 5~14 days Clinical types Covert infection: >90% Abortive poliomyelitis: 4~8% Non-paralytic poliomyelitis: Paralytic poliomyelitis: 1%~2% Clinical manifestation Paralytic poliomyelitis Prodromal period preparalytic period paralytic period convalescent period sequela period Clinical manifestation Prodromal period:(1~4d) upper respiratory tact infection: fever, fatigue, sore throat, headache intestinal tract infection: vomiting, diarrhea, constipation abortive poliomyelitis Clinical manifestation Preparalytic period progressing this phase without prodromal phase 1~6days after symptoms of prodromal phase without prodromal phase Clinical manifestation Preparalytic period fever: two-hump fever(10~30%) symptoms & signs of CNS severe headache & vomiting dysphoria or lethargy muscle pain Clinical manifestation Preparalytic period symptoms & signs of CNS cutaneous hyperesthesia hyperhidrosis meningeal irritations (neck stiffness Kernigs & Brudzinskis signs positive) 3~6d , nonparalytic poliomyelitis Clinical manifestation Paralytic period paralysis types spinal type brain stem type mixed type brain type Clinical manifestation Paralytic period Spinal type: most common paralysis features: flaccid (hypomyotonia ,tendon reflexes are weak or absent) asymmetric distribution: without sensory loss 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 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: Clinical manifestation Paralytic period brain type - polio-encephalitis high fever, convulsion, disturbance of consciousness, tonic paralysis mixed type spinal type + brain stem type 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 Clinical manifestation Sequela period persistent paralysis muscular atrophies deformities of limbs Laboratory Findings Cerebrospinal fluid aseptic menigitis pleocytosis: 50~500×109/L protein: normal or slightly increase albuminocytologic dissociation glucose and chloride; normal virus isolation: pharynx, feces, blood or CSF,brain. Laboratory Findings Serological test: Specific IgM Ab (blood & CSF) Neutralized Ab Complement combining Ab four fold rise Diagnosis Epidemiological data: Clinical manifestation: Laboratory findings: Abortive or non-paralytic polio isolation of virus or serological test paralytic polio - clinical diagnosis 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 Differential Diagnosis Paralysis caused by other enterovirus Coxsackie or ECHO viruses: no epidemic no sequelae 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 Treatment Paralytic period: limb paralysis nursing for paralytic limbs Put the limbs on function position Vit C ATP ivdrop Galanthamin or Prostipmin iM Treatment treatment for respiratory obstacle bulbar paralysis dysphgia keep air way clear (sputum aspiration postural drainage ) tracheal intubation tracheotomy tank respirator Treatment treatment for respiratory obstacle respiratory center paralysis respiratory stimulant tracheotomy tank respirator respiratory muscle paralysis mild observation tank respirator Treatment Convalescent & sequela period acupuncture massage 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