A CASE PRESENTATION ON POLIOMYELITIS

PRESENTED TO: ALBERTO GILBERT GUZMAN, PTRP

PRESENTED BY: BSN 1V ARJAN, MUJIBA GALAROSA, WILMAE S. GAWARAN , MARK ANTHONY MOHAMMAD, JAIMA SARDENIA CHRISTINE MARIE

organ affected
CENTRAL NERVOUS SYSTEM THE BRAIN

Polioviruses can attack motorneurons in the anterior horn of the spinal cord and in the bulbar area.

NORMAL FUNCTION Central Nervous System

Anatomy and Physiology I

Spinal Cord
Located within the dorsal vertebral column From base of the brain to the pelvis
In humans the posterior few segments are filled with nerves that supply the pelvis, buttocks &
legs

Gray matter around a central canal - butterfly shape

Cell bodies, dendrites & synapses White matter surrounds gray matter Bundles of myelinated axons that connect different parts of the cord

Spinal Nerves - Sensory & motor

Dorsal root - sensory - dorsal root ganglion (sensory cell bodies) Ventral root - motor

Spinal Nerves
31 pairs

Lobes of the Brain

Boundaries between not always clearly delineated - therefore just indicate general regions

Frontal lobe Parietal lobe Occipital lobe Temporal lobe

Brain Architecture
Front part of the brain increases in size & surface area from fish to mammals The surface thrown into folds - gyri (gyrus - singular) The grooves between the folds are sulci (sulcus - singular)

Cellular organization

Tracts occur on the surface & deeper Gray matter - forms distinct collections of cell bodies - nuclei Cortex - opposite of spinal cord

Outside - gray matter with white below (complex tangles of tracts below - with deep nuclei)

Mammalian Brain
Forebrain - prosencephalon

Telencephalon - cerebral hemispheres - higher functions, motor control & sensory processing

Diencephalon

Thalamus - sensory relay

Lateral geniculate - visual Medial geniculate - auditory

Hypothalamus - homeostasis control center Pituitary gland - master endocrine gland

Basal ganglia - Motor planning & Control (Distinct nuclei) Limbic system - Emotions & Memory (distinct nuclei) Midbrain - Mesencephalon

Tectum - sensory processing center

Superior colliculus - oculomotor reflexes (visual processing - lower vertebrate) Inferior colliculus - Auditory relay & processing Tegmentum - orientation reflexes & auditory Red nucleus - postural reflexes & motor control Substantia nigra - postural reflexes & motor control & linked with limbic system

Mammalian Brain
Hindbrain - Rhombencephalon
Metencephalon
Cerebellum - coordination & learning Pons - control of respiration Medulla oblongata - control of respiration, heart rate, blood pressure, vomiting & coughing

Central Core of the Brain

Tube expands during development - forms the ventricles or chambers of the brain Fourth ventricle - chamber of the hindbrain Third ventricle - chamber of the forebrain
Connected to the 4th ventricle by the cerebral aqueduct - passes through midbrain

Right & left ventricles - expansions of the third ventricle in the telencephalon

External Covering of the Brain

Meninges - three membranes Outermost - dura mater - tough inelastic bag surrounds the brain & spinal cord Middle most membrane - arachnoid membrane - appearance & consistency resembling a spider Pia mater is separated from the arachnoid by fluid filled subarachnoid space
web Innermost - pia mater - thin membrane that adheres closely to the surface of the brain

Cerbrospinal Fluid - CSF

Produced by chroid plexus in the walls of the ventricles of the cerebral hemispheres CSF flows from the paired ventricles then to the third & fourth ventricles
then to the central canal of the spinal cord

 CSF escapes into the subarachnoid space via small apertures near the base of the
cerebellum In the subarachnoid space, CSF is absorbed into the blood

Clear colorless fluid containing ions & little protein fills the central canal of the spinal cord and the ventricles Also circulates over surface of the brain - acts as shock absorber

The Lower Brain - Brain Stem

Medulla - from spinal cord Pons - from anterior medulla - bulging area - external surface ribbed Cranial nerves 5 through 12 arise from the brain stem Fiber tracts
Pyramidal tracts - ventrally located - motor
Corticospinal - cortex to spinal cord Spinocortical - spinal cord to cortex Reticular system - loose network of of neurons - reticular activating system

Modulate sensation of pain Modulate certain postural reflexes & muscle tone Control breathing & heart rate Regulate the level of brain arousal & in humans consciousness Receives massive sensory input

The Cerebellum
Part of the hindbrain - not brain stem Connected to pons via cerebral peduncles
Represent thousands of fibers going into or out of the cerebellum

A central point for motor organization. Yet it does not initiate movement and movement
can be generated in the absence of it The cerebellum modulates or reorganizes motor commands - and by coordinating diverse signals, it obtains the maximum efficiency from them Lesions - produce disturbances in the coordination of limb and eye movements and disorders of muscle tone and posture Principal cell - Purkinje cell - projects to deep cerebellar nuclei

The Midbrain
Sits between hindbrain & forebrain Major thruway for axon tracts that connect the above two regions Tectum in lower vertebrates - visual processing
In mammals - same area called superior collculus

Inferior colliculus - dorsal surface of midbrain - auditory Tegmentum - below the aqueduct - largest midbrain area

 Red nucleus & substantia nigra - orientation reflexes

The Diencephalon
Lower part of the forebrain Parts - Thalamus & hypothalamus Thalamus - major relay for sensory information
Lateral geniculate nucleus -paired - visual input Medial geniculate nucleus - paired - auditory input

Hypothalamus - regulates internal environment

Initiate or suppress behaviors to maintain homeostasis Regulate pituitary gland - which regulates endocrine system Controls autonomic nervous system - to regulate homeostasis

The Telencephalon
Upper part of the forebrain Half the brain volume Cerebral hemispheres - paired lobes - together called cerebrum
Outer layers - cell bodies , dendrites & synapses - gray matter - cerebral cortex Hemispheres joined by corpus callosum Central sulcus - divides hemispheres into anterior & posterior halves

Precentral gyrus - just ahead of the central sulcus - motor cortex Postcentral gyrus - sensory processing from body surface & muscles

The basal ganglia nuclei clustered around the thalamus

Functions as an entity partially devoted to sequencing individual motor programs into smooth
series of actions

Gate sensory influences into motor areas Regulate sensimotor interactions in a way that determines which sensory stimuli are use to
initiate motor actions and which are disregarded

Components

Striatum (caudate + putamen) Globus pallidus Subthalamic nucleus - in diencephalon Substantia nigra - in midbrain

Autonomic Nervous System

Sympathetic NS

Parasympathetic NS Enteric NS Neurons of Autonomic Nervous System

Preganglionic
Cell bodies in spinal cord or brain stem

Postganglionic
Cell bodies in peripheral autonomic ganglia

Visceral Afferents

Peripheral Sympathetic NS

 Preganglionic - in thoracic & upper lumbar spinal cord

Axons run in autonomic ganglia Postganglionic
Axons in sympathetic chain or paravertebral ganglia

Effector organs
Blood vessels, hair, viscera, pupils, cardiac muscle, glands

Sympathetic NS
Inhibitory effect on non sphincter muscle of viscera, digestive glands & SM of bronchi. All other effects excitatory!

Pattern of Sympathetic Connection Parasympathetic NS

Preganglionic - in sacral cord and brain stem
Vagus (CN X) - 75% of parasymp. outflow

Postganglionic - short fibers All parasymp. innervated organs also sympathetically innervated
e.g. bladder, rectum,GI tract, heart, lungs, lacrimal & salivary glands

Parasympathetic NS Not all Sympathetically. innervated structures are parasympathetically.

innervated Exceptions

Entire vascular system, adrenal medulla & pilomotor muscle - only sympathetically
innervated.

Functions of the Autonomic NS

Sympathetic and Parasympathetic systems are antagonistically organized Sympathetic - largely fight or flight response
Works with adrenal medulla - epinephrine

Parasympathetic - antagonizes sympathetic activity

Not normally activated as a whole

Neurotransmitters of the Autonomic NS

All preganglionic fibers - cholinergic Postganglionic parasympathetic fibers - cholinergic Postganglionic sympathetic fibers - NE - adrenergic Some sympathetic - cholinergic
Sweat glands & blood vessels of skin and skeletal muscle

DEFINITION: - is an acute infectious disease caused by any of the three types of Poliomyelitis virus which affects chiefly the anterior horn cells of the Spinal cord and the medulla, cerebellum and midbrain. - Characterized by two febrile episodes, a minor and major illness separated by a remission of one or two days followed by varying degrees of muscle weakness or occasionally a progressive Paralysis that ends fatally. SYNONYMS: Acute Anterior Poliomyelitis; Heine-Medin Disease: Infantile Paralysis. ETIOLOGY AND EPIDEMIOLOGY: - the causative virus is poliovirus (Legio Debilitants) - there are 3 distinct serelogic types of poliovirus (with no cross Immunity) 1) Type I is the most paralytogenic or the most frequent cause of Paralytic poliomyelitis, both epidemic and endemic. 2) Type II the next most frequent. 3) Type III the least frequently associated with paralytic disease. Types of Poliomyelitis 1) Spinal Cervical Thoracic Lumbar 2) Bulbar Cranial nerves Circular System Respiratory System 3) Bulbo-spinal 4) Polioencephalitis

PERIOD OF COMMUNICABILITY: Most contagious a few days before and after the onset of symptom when the virus is found in the oropharynx for about a week, and in large quantities in the small bowel, and continues to be in feces up to about 3 months. Modes of Transmission: - virus is harbored in GIT and is transmitted through saliva, vomitus and feces 1) Direct contact from one person to another person through healthy carriers via the intestinal/oral pathways. - it has been shown that poliovirus excretors are much more commonly found among householdor family contacts than among noncontact. 2) Indirect contact fecal-oral through food, water, utensils and objects contaminated by human exreta. - occasionally, the virus may be implanted through the oropharynx and in very rare instances by parenteral. INCUBATION PERIOD:

- Usually 7-14 days, with a range of 5-35 days, for paralytic and non-paralytic forms; 3-5 days for the minor illness.

PATHOGENESIS: - polio virus reaches the intestinal tract through the mouth, enters the intestinal mucosa and lodges and multiplies in undetermined sites, possibly reticuloendothelial system. This is known as the Intestinal Phase. - The organism may then reach the blood (viremic phase) and then proceed to CSN (neural phase) - In each of these stages the body defences respond and resist the invading organisms. - The disease may stop in any of this sites, depending on the promptness and effectiveness of the hosts antibody response at that particular phase. - Thus if the virus is inhibited or is stopped from increasing at the intestinal phase, adequate immunity develops locally in the intestine as well as systematically, with hardly any clinical manifestations. This is what happens in the asymptomatic, silent or subclinical manifestations. This is also the principle of oral vaccination. - If the virus proceeds unabated, it enters blood stream resulting in systemic manifestations which, depending on the severity of infection may present dregs of fever, headache, vomiting, and irritability. - The milder manifestations constitute the Abortive type of the disease and the more severe manifestations; the Meningitic or preparalytic Type. - Unchecked, the organism proceed via nerve pathways to the CNS and again depending on the site they invade, manifestations may correspondingly be Spinal, Bulbospinal or Encephalit CLINICAL MANIFESTATIONS: 4 Clinical forms are described: 1) Inapparent/Subclinical/Asymptomatic/Silent Type - person who are expose to poliomyelitis ward like the nurses and other members of the health team. But not all polio victim has small leg or both. 2) Abortive Type/Minor Illness of Poliomyelitis: - starts with a mild to moderate upper respiratory infection or with symptoms of mild influenza like slight fever, malaise, headache, sore throat, inflamed pharynx and vomiting. This is follows by a remission of 1-2 days at which time the child may be active and playful. - This case may be unnoticed. 3) Preparalytic or Meningitic Type/Major Illness of Poliomyelitis:

- then the second febrile stage is observe, this time with higher temperature, headache, vomiting, restlessness, anorexia, lethargy and pain in the neck and back, arms, legs, and abdomen. - It cause also muscle spasms and tenderness in the extension or extensora of neck and back. - Is usually lasts about a week with meningeal irritation persisting for about 2 weeks. 4) Paralytic Type - early manifestations are pain and some degree of stiffness followed by twitching and diminished deep tendon reflexes. - There may be hyperesthesia and irritability. - Loss of tendon reflexes, positive Kernigs Sign and Brudzinskis Sign - In one or two days later, weakening of muscle plus paralysis. - Positive Hoynes Signs- his head will fall back when he is in supine and his shoulders are elevated. He wont be able to raise his legs at full 90 degrees. DIAGNOSIS: 1. Isolation of the Virus 1. 2. 3. Blood- end of first week; WBC may be normal or slightly increased Throat- end of first week until second week Fecal/Stool- first week until third week

2. With CNS, CSF examination a.CHON- normal and moderately elevated as disease progress b. Sugar/Glucose content is normal TREATMENT: 1. Abortive Type/Minor Illness Bed rest Analgesic-to ease headache, back pains and muscle spasm 2. Preparalytic or Meningitic Type/Major Illness Moist hot packs for 15-30 min every 2-4 hrs over the affected muscles Anxiety and fear should be allayed The limb should be in a position of comfort 3. Paralytic Type ( hospitalization required) Suitable body alignment; feet at the right angle, knees slightly flexed, hips and spine straight, with the use of board, sand bags, and occasionally light splint shells Active and passive movements as soon as pain disappears Avoid fecal impaction

 Maintain good body alignment by using boards, sand bags, etc. Make bed with cotton or woollen blanket both under and over the pt. Change position frequently Daily bath if necessary and change wet clothes 4. To avoid spread of microorganism Secretions should be properly disposed Avoid contact with person having known cases Nasal and oral hygiene PREVENTION: 1. Administration of polio vaccine a. Salk Vaccine- solution of killed viruses that given intramuscularly b. Sabin Vaccine- which is preparation attenuated living viruses that is administered orally. 2. Effective Immunization-programs may be achieved carried out community wide to include all infants over 2 months old, children and young adults with the preschool age group as priority target. COMPLICATION 1. Respiratory paralysis- which includes the diaphragm and the inter costal muscle 2. Pneumonia 3. Myocarditis 4. Atelectasis 5. Pulmonary edema 6. Acute gastric dilatation, melena 7. Hypertension 8. Renal calculi 9. Late complication- skeletal and soft tissue deformity DIAGNOSIS 1) ISOLATION OF THE VIRUS a) Blood- by the end of the 1st week, WBC count may be normal or slightly increased. b) Throat- by the end of the 1st week until the 2nd week c) Fecal/stool- by the end of the 1st week until the 3rd or throughout the disease and even up o 3 months. d) CSF- is not a path gnomonic but may be help when considered with other manifestations and the course of the disease. 2) SEROLOGIC DIAGNOSIS

- is of value when there is at least a 4 rise of antibody titer from the acute to the acute to the convalescent stage, as determined by neutralization or complement fixation tests. 3) WITH CNS INVOLVEMENT, CSF EXAMINATION: a) Pleocytosis with early predominance of polymorph nuclear cells followed by a shift to mononuclear cells. b) Proteins- normal in the early stage of the disease and may be moderate elevated as disease progresses c) Glucose/sugar content is normal. PROGNOSIS - recovery from the nonparalytic form of poliomyelitis is usually complete. - In paralytic poliomyelitis, the degree of disability that results depends on the extent of involvement and the management. - Recovery of muscle function usually occurs spontaneously within a few weeks. - Muscles which are paralyzed in 1 month after the onset of illness recover completely only in less than 2% of the cases. - Over all mortality for the paralytic form is about 4% - Prognosis is poorer in order children and adults. - Bulbar poliomyelitis is always serious particularly when the medulla and respiratory muscles are involved. PREVENTION 1. Administration of polio vaccine 1. 2. Salk Vaccine- solution of killed viruses that given intramuscularly. Sabin Vaccine- which is a preparation attenuated living viruses that is

administered orally: Examples: Live Attenuated Trivalent Vaccine or Trivalent Oral Polio/Virus Vaccine (TOPV). - immunity confers long lasting - A booster dose after a year is recommended in low socioecomomic areas where the high incidence of other enteroviruses may cause interference of immunity. 2. Effective Immunization - Programs may be achieve if carried out community wide to include all infants over 2 months old, children and young adult with that preschool age group as priority target.

Special cansiderations of Poliomyelitis:

Observe the patient carefully for signs of paralysis and other neurologic damage, which can occur rapidly. Maintain a patent airway, and watch for respiratory weakness and difficulty in swallowing. A tracheotomy is commonly done at the first sign of respiratory distress, after which the patient is placed on a mechanical ventilator. Remember to reassure the patient that his breathing is being supported. Practice strict aseptic technique during suctioning, and use only sterile solutions to nebulize medications. Perform a brief neurologic assessment at least once a day, but don't demand any vigorous muscle activity. Encourage a return to mild activity as soon as the patient is able. Check blood pressure frequently, especially in bulbar poliomyelitis, which can cause hypertension or shock because of its effect on the brain stem. Watch for signs of fecal impaction (due to dehydration and intestinal inactivity). To prevent this, give sufficient fluids to ensure an adequate daily output of low specific-gravity urine (1.5 to 2 L/day for adults). Monitor the bedridden patient's food intake for an adequate, wellbalanced diet. If tube feedings are required, give liquid baby foods, juices, lactose, and vitamins. To prevent pressure ulcers, provide good skin care, reposition the patient often, and keep the bed dry. Remember, muscle paralysis may cause bladder weakness or transient bladder paralysis. Apply high-top sneakers or use a footboard to prevent footdrop. To alleviate discomfort, use foam rubber pads and sandbags, as needed, and light splints, as ordered . To control the spread of poliomyelitis, wash your hands thoroughly after contact with the patient, especially after contact with excretions. Instruct the ambulatory patient to do the same. (Only hospital personnel who have been vaccinated against poliomyelitis may have direct contact with the patient.) Provide emotional support to the patient and his family. Reassure the nonparalytic patient that his chances for recovery are good. Long-term support and encouragement are essential for maximum rehabilitation. When caring for a paralytic patient, help set up an interdisciplinary rehabilitation program. Such a program should include physical and occupational therapists, physicians and, if necessary, a psychiatrist to help manage the emotional problems that develop in a patient suddenly facing severe physical disabilities.

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