Suryadi Susanto

Krida Wacana Christian University

Pediatric Department
 RNA viruses
 Picornaviridae family
 genus Enterovirus
 3 serotypes (types 1, 2, and 3)

 Extremely hardy and can retain infectivity for several days at

room temperature
 The most devastating result of poliovirus infection is paralysis
 90–95% of infections are inapparent but induce protective
immunity.
 Paralytic polio 1/1,000 infections among infants
1/100 infections among adolescents.

 Poor sanitation and crowding

 Humans are the only known reservoir for the polioviruses,

(fecal-oral route)
 Transmission: can be isolated from feces prior paralysis and
after the onset of symptoms

 The primary site of replication is in the M cells lining the

mucosa of the small intestine.
 Regional lymph nodes are infected
 Primary viremia occurs after 2–3 days

 The virus penetrates the cell  releases viral RNA (translated

to produce proteins for replication of the RNA)
 shut-off of host cell protein synthesis
 Synthesis of structural elements
 Mature virus particles are produced in 6–8 hr
 The exact mechanism of entry into the CNS ???
 Primarily infects motor neuron cells in the spinal cord (the
anterior horn cells) and the medulla oblongata (the cranial
nerve nuclei)

 Infants acquire immunity transplacentally from their mothers.

 Transplacental immunity disappears at 1st 4–6 mo of life.
 The incubation period of poliovirus 8–12 days (range of 5–35
days)

I. Abortive Poliomyelitis. (5%)

 A nonspecific influenza-like syndrome: fever, malaisea,
anorexia, and headache are prominent features
 Short lived, up to 2–3 days.
 PE normal or may reveal nonspecific pharyngitis, abdominal or
muscular tenderness, and weakness.
 Recovery is complete
 No neurologic signs or sequelae develop.
II. Nonparalytic Poliomyelitis (1%)
 Wild-type poliovirus
 Signs of abortive poliomyelitis
 Approximately ⅔ of these children have a short symptom-free interlude
between the 1st phase (minor illness) and the 2nd phase (CNS disease or
major illness).
 Nuchal and spinal rigidity are the basis for the diagnosis of nonparalytic
poliomyelitis during the 2nd phase.

PE
 nuchal-spinal signs and changes in superficial and deep reflexes.
 In the early stages the reflexes are normally active and remain so unless
paralysis supervenes.
 Superficial reflexes, reflex of spinal and gluteal muscles are usually the 1st to
diminish.
 Tendon reflexes are absent with paralysis.
 Sensory defects DO NOT occur.
III. Paralytic Poliomyelitis. (0.1%)
 causing 3 clinically recognizable syndromes :

1. Spinal paralytic poliomyelitis may

 occur as the 2nd phase of a biphasic illness
 the 1st phase of which corresponds to abortive poliomyelitis.
 Severe muscle pain and sensory and motor phenomena
 PE distribution of paralysis is characteristically spotty  1–2 days
asymmetric flaccid paralysis or paresis
 Involvement of 1 leg is most common, followed by involvement of 1
arm.
 The proximal extremities tend to be involved to a greater than the
distal areas.
2. Bulbar poliomyelitis
 may occur as a clinical entity without apparent involvement of
the spinal cord.
 Dominance of dysfunctions of cranial nerves and medullary
centers
 Clinical finding: respiratory difficulty

3. Polioencephalitis
 A rare form with higher centers of the brain are severely
involved.
 Seizures, coma, and spastic paralysis with increased reflexes
may be observed.
 Poliomyelitis should be considered in any unimmunized or
incompletely immunized child with paralytic disease.

 VAPP (Vaccine-associated Paralytic Poliomyelitis) should be

considered in any child with paralytic disease occurring 7–14
days after receiving the orally administered polio vaccine
(OPV).

 The World Health Organization (WHO) recommends :

 isolation and identification of poliovirus in the stool
 specific identification of wild-type and vaccine-type strains.

 Isolated from 80–90% of acutely ill patients

 The CSF
 Often normal and typically pleocytosis during the minor
illness
 CSF protein is normal or only slightly elevated at the outset
of CNS disease but usually rises to 50–100 mg/dL by the 2nd
week of illness. In polioencephalitis, the CSF may remain
normal or show minor changes.
 Any case of paralysis
 VAPP
 West Nile virus
 Guillain-Barré syndrome
 Transverse myelitis
 Traumatic nueritis
 Conditions causing pseudoparalysis (do not present with
nuchal-spinal rigidity or pleocytosis)
 Unrecognized trauma
 Transient (toxic) synovitis
 Acute osteomyelitis
 Acute rheumatic fever
 Scurvy
 Congenital syphilis (pseudoparalysis of Parrot).
 No specific antiviral

 Supportive
 Limiting progression of disease
 Prevention skeletal deformities
 Preparation for prolonged treatment required and
permanent disability

 Nonparalytic and mildly paralytic forms : treated at home

Abortive Poliomyelitis

 Supportive
 analgesics, sedatives
 an attractive diet
 bed rest until the child's temperature is normal
Nonparalytic Poliomyelitis

 Similar to abortive form

 Analgesics + hot packs for 15–30 min every 2–4 hr.
 Hot tub baths are sometimes useful.
 A firm bed
 carefully examined 2 mo after apparent recovery
Paralytic Poliomyelitis

 Most require hospitalization

 complete physical rest
 Neutral position
 Active and passive movements
 Moist hot packs
 Opiates and sedatives
 Fecal impaction
Pure bulbar poliomyelitis

 Maintaining the airway

 Avoiding risk of inhalation of saliva, food, or vomitus

 Impaired ventilation must be recognized early

 Tracheostomy
 Paralytic poliomyelitis may be associated with numerous
complications.
 Acute gastric dilatation (acute or convalescent stage)

 Melena

 Mild hypertension, hypercalcemia, nephrocalcinosis, and

vascular lesions.
 Abortive poliomyelitis and aseptic meningitis syndromes : good

 Paralytic disease is determined primarily by degree and severity of CNS

involvement.

 Severe bulbar poliomyelitis : mortality rate can reach 60%

 Maximum paralysis usually occurs 2–3 days after the onset of the paralytic
phase of the illness

 The recovery phase lasts usually about 6 mo

 Male children and female adults, generally, are more likely to develop
paralysis.

 Increased physical activity, exercise, and fatigue  paralytic disease.

Postpolio Syndrome.

 After an interval of 30–40 yr (30–40%)

 muscle pain

 exacerbation of existing weakness

 new weakness or paralysis

 only who infected in the era of wild-type poliovirus circulation.

 Vaccination
▪ IPV
▪ OPV
▪ 4 doses of IPV at 2 mo, 4 mo, 6mo, 18 mo, and 5 yr of age.

 Hygienic measures help limit the spread of the infection