Acute Flaccid Paralysis

Oleh: Mia Audina

Pembimbing: Dr. Liza Chairani, Sp.A, M.Kes
 

PENDAHULUAN

•
 WHO: extremity
weakness of fast-
onset individuals,
DIAGNOSA
often including
weakness of
• WHO: 200 Diagnosis: There are many
respiratory muscles •

30% - 60% na
namel
mely
y AFP
and swallowing,
develops to GBS. complications
maximum severity in • Minister of Health RI: In such as: skeletal
1-10 days Indonesia 32 diagnoses: deformity to
Poliomyelitis, death due to
• Menk
Me es RI : all
nkes
Polioencephalitis,
children aged less respiratory
Guillan
Guillan-Bar
-Barre
re Syndrome
Syndrome,,
than 15 years with
Transverse myelitis, muscle paralysis
paralysis that isoccur
flaccid (layuh), Flaccid muscle paralysis, Therefore
referrals write
Transient paralysis of a
acutely (suddenly),
limb, and mononeuritis.
not caused by forced
ruda • number of cases of Non
Polio AFP Indonesia
2017: 1409, with the
number of cases in
definisi southern Sumatra: 51
 

LITERATURE REVIEW…
 

Definition
  Acute flaccid paralysis (AFP) is defined as all children
children
younger than 15 years with flaccid (layuh) paralysis,
occurring acutely (suddenly), not caused by forced ruda.

acute
flaccid

rapid progressive
development
14 days from between
the onset1-
of limp paralysis,
or stiffness weakness
is not stiff, or
initial symptoms (pain, a decrease in muscle
tingling, thickness / tone.
numbness) to maximal
paralysis
 

Symptoms

Weak
symmetrical
proximal
muscles
Muscle
Autonomic weakness
dysfunction due to
fatigue

Symmetrical
quadriparesis
flaccid

Ophthalmop
legia Flaccid
paraparesis
accompanie with sensory
d by motor level
weakness disorders
Damage
that covers
the medulla
oblongata
 

Physical examination

Assess
distribution and Spinal
Reflexes.
degree of tenderness.
weakness.

Pain when the

Sensory General
limbs are lifted
disorders. description.
(radiculopathy).
 

Scale of muscle strength

Value interpretation
5/5 Able to move joints in full motion, able to resist gravitational
forces, able to fi
fig
ght with full prisoners.

4/5 Able to move joints with gravitational force, able to fight with
moder
moderate
ate pri
prison
soners
ers

3/5 Only able to fi

Onl fig
ght gr
graavity.
2/5 Unab
Unable
le to re
resi
sist
st gr
gra
avi
vitty (p
(pas
assi
siv
ve mo
move
vem
men
ent)
t)..

1/5 Muscle contractions can be palpated without moving the

 joints.
0/5 Ther
Th ere
e is no muscle con
onttraction
 

Causes of AFP(K
(Keme
emenke
nkes
s RI 2007
2007))

 Poliomyelitis  Quadriplegia/Tetraplegia
 Polioencephalitis  Plegia-unspecified

 Guillan-B
Guillan-Barr
arre
e Sy
Syndr
ndrome
ome  Plegia-other
 Transverse myelitis  Flaccid muscle paralysis
 Paraplegia  Transient paralysis of a limb
 Diplegia  Myelitis postvaccinal
 Monoplegia-upper  Monone
Mononeuri
uritis
tis upp
upper-
er-limb
limb
 Monoplegia-lower  Monon
Mononeur
euriti
itis
s low
lower-
er-limb
limb
 

Peripheral Acute Myelopathy

neuropathy (Cord compression , Demyelinating
( Anterior hor
horn
n cell disease, M
Muscle
uscle diseases,, Ischa
diseases Ischaemic
emic cord damag
damage
e)
disorders)

Disorders of
Systemic disease neuromuscular
(Acute porphyrias, Critical illness transmission
neuropathy, Acute myopathy in ICU (Myasthenia gravis, Botulism. Insecticide
patients) (organophosphate poisoning), Tick bite
paralysis, Snake bite)
 

Supporting investigation

lumbar
puncture

tensilon
test /
prostigmin Blood test
test

neuroimaging

electrophy serum
protein
siological
electropho
test
resis
paraneopla
stic
antibody
screening
 

Penatalaksanaan

airway breathing circulation

• Make sure • Ensure • Check

the airway adequate blood
is awake ventilation pressure /
pulse
frequency

Special management
according to the
disease diagnosed
 

Report it
immediately Supportive Symptomatic

examination
Education Physiotherapy of faecal
specimens
 

Differential diagnosis
Poliomielitis Guillain-bare Myastenia Gravis

Onset gradually Quickly and suddenly Gradual and volatile

Simetris unilateral bilateral unilateral

Fever + + -

Autonomic nervus abnormal abnormal normal

System
Sensoric fx abnormal abnormal normal

Swallowing disorder + + +

N III,IV,VI Disorder - + +

Respiratory Disfungtion - + +
N VII disorder - - +

Physiologic reflx - - -

Prognosis Slow healing Slow healing Remition-Relaps

Therapy
Therapy Salin hiper
hipertonik
tonik,, aspirin
aspirin,, Physical therapy, Neostigmin, efedrin,
diazepam, physical plasmaferesis, steroid, timektomi
therapy, immunization IVIg, steroid
 therapy, immunization IVIg, steroid
 

Poliomielytis
(synonim:Acute anterior poliomeilytis,
poliomeilytis, infantile
infantile paralysis,
paralysis, penyakit
penyakit
Heine
Heine dan
dan mei
meidi
din)
n)

 paralysis or paralysis caused by a virus, namely

poliovirus (PV), enters the body through the mouth,
infects the intestinal tract. This virus can enter the
bloodstream and flow to the central nervous system
causing weakening of the muscles and sometimes
paralysis (paralysis).
 

Poliomielitis
Clinical manifestations

1. Abortive
Abortive polyomy
polyomyelitis:
elitis: malais
malaise,
e, anorexia,
anorexia, nausea
nausea,,
vomiting, headache, sore throat, constipation, and
abdominal pain.
2. Nonpar
Nonparaly
alytic
tic pol
polyo
yomy
myelit
elitis:
is: sympt
symptoms
oms are like
like abortiv
abortive
e
poliomyelitis except for more severe headache, nausea
and vomiting and there is pain and stiffness of the
posterior neck muscles, body and legs. Physical
examination shows signs of stiff neck.
3. Paraly
Paralytic
tic polyomeilit
polyomeilitis:
is: symptoms
symptoms areare like abortive
abortive
poliomyelitis, with pain, spasticity,
spasticity, neck stiffness and
spinal stiffness, and hypertension at the onset of the
disease. On physical examination the typical paralysis
distribution is sometimes not.
 

Poliomyelitis
Diagnosis

History and physical fecal examination

examination

Blood test Viral breeding

 

Poliomielitis
Treatment

There is no causal
treatment, but
poliomyelitis can be
prevented through
vaccination.
 

Poliomielitis
complication

• • •
Progressive
muscle paralysis
the chest of Permanent
paralysis
weakness muscles
 

Sindrom Guillain-Barre

comprehensive polioneuritis,
can be acute or subacute, may
occur spontaneously or after
an infection, and on
pathological examination:
there is no sign of
inflammation
 

Sindrom Guillain-Barre
Clinical Manifestations

 It is usually preceded by fever or upper respiratory tract

disease

 Asending par
Asending paralysis
alysis is paraly
paralysis
sis
 Flaccid type paralysis
 Paralysis can be preceded by hypesthesia, painful
Paralysis
anesthesia or paresthesia

the affected muscles are symmetrical.
 

Sindrom Guillain-Barre
Diagnosis

 History and physical examination

 Cerebrospinal fluid examination:
- CSS
CSS pro
prote
tein
in in
incr
crea
ease
ses
s to>
to> 2x
2x nor
norma
mall
- Fou
ound
nd les
less
s tha
than
n 10
10 whi
white
te bl
bloo
ood
d cell
cells
s / mm
mm3
3
- The res
result
ults
s of
of nega
negativ
tive
e bact
bacteri
erial
al cul
cultur
tures
es and vir
viral
al
cultures rarely isolate certain viruses
 

Sindrom Guillain-Barre
Therapy

supportive action and physiother

physiotherapy:
apy:
 - If you need to do a tracheosto
tracheostomy
my,, breathing apparatus
apparatus if
the vital capacity drops below 50%
 - if there is bulbar
bulbar paralysis
paralysis or dysphagia
dysphagia,, nasogastric
nasogastric or
gastrostomy is needed for feeding
 - Provi
Provision
sion of
of corticost
corticosteroids
eroids:: reduce pain
pain
 - pla
plasa
saph
pher
eres
esis
is
 

Sindrom Guillain-Barre
Prognosis

 Good especially in children. Usually the repair is seen

within 7-10 days and perfect healing without sequelae
but sometimes healing lasts a long time.
 Death is caused by paralysis of the respiratory
r espiratory muscles
 

Neuritis traumatika

 Can be caused by trauma,

- direct
directly
ly for example
example due to injection
injection (butt
(butt injection
injection

dropfoot
dropfo ot and del
deltoi
toid
d dropha
drophand
nd inj
inject
ection
ion))
- indirec
indirectly
tly can be
be an inju
injury
ry or nerve
nerve pressure.
pressure.
 APF can occur within a few hours
hours to several
several days after
trauma.
 Symmetrical, lasid, and areflexia.
 

Myastenia gravis

an autoimmune disorder (at

the neuromuscular junction)

that is characterized
abnormal by an
and progressive
weakness in the skeletal
muscle that is used
continuously and is
accompanied by fatigue when
on the move.
 

Myastenia gravis
Diagnosis

Vocal cord Wartenberg

test Patients are test The patient is

assigned to assigned to
count in a loud blink his eyes
voice continuously

Over time it will

be heard that Over time
his voice is ptosis will arise
getting weaker
 

Myastenia gravis
Diagnosis

• injected 2 mg of • injected 3 cc or 1.5 • 3 tablets of quinine

tens
tensilon IV  If
ilon mg prostigmin were given for each
weak muscles merhy
mer hylsu
lsulfa
lfate
te IM  200 mg3 hours
experience symptoms of then 3 tablets were
improvement  weakness given againif the
positive tests disappear symptoms gained
positive weightpositively
Tensi
ensilon
lon Test Prostigmin
(edrophonium Test Ki
Kini
nin
n Tes
estt
chloride) (neostigmin)
 

Miastenia Gravis
management

 Get it with drugs or thymomectomy.

 Short-term therapy:
therapy: plasma exchange (PE)2 or with
Intravenous
Intravenous Immunoglobulin (IVIG)2
 Long-term therapy:
Long-term therapy: immunomod
immunomodulati
ulating
ng and
immunosuppressive with drugs such as corticosteroids,
azathioprin
azathioprine,
e, cyclosporin
cyclosporin and cyclophosp
cyclophospamide
amide
 

Myelitis transversa (TM)

neurological disorders caused

by the inflammatory process of
the white and gray matter of
the spinal cord, and can cause
axonal demyelination.
 

Myelitis transversa
symptoms

 weakness and numbness in both legs

 sensory and sphincter deficits

 Low back pain can occur in some patients
 Onset occurs suddenly and develops quickly in a few
hours and several days
 

Myelitis transversa
Cause

 TM can arise in isolation or with other diseases.

 When TM arises without visible comorbidities, it is
is
assumed to be idiopathic
assumed idiopathic (abnorm
(abnormal
al imune syste
system
m
against spinal cord)
 TM often occurs together with bacterial and viral
infections. 1/3 of patients with TM report flu-like
flu -like illness
with fever.
 

Myelitis transversa
Therapy

 Therapy is usually only symptomatic, corticosteroids are

used as a therapy for inflammation of the spinal cord
 Plasma exchange
exchange or radical immunosupr
immunosupressan
essantt ther
therapy
apy
that can be used more if the steroid does not work
 Patients should follow a rehabilitation regimen for spinal
damage
 

SIMPULAN

Acute flaccid paralysis Acute: rapid progressive

Acute: Case of AFP: Poliomyelitis,
(AFP ):
): all children aged less between 1-14 days Polioencephalitis,
Polioencepha litis, Guillan-
than 15 years with flaccid Barre Syndrome, Transverse
(layuh) paralysis, occur Flaccid:
weaknesslimp paralysis,
or stiffness not stiff
stiff,, myelitis, Flaccid muscle
acutely (suddenly), not  paralysis,, Transient paralysis
 paralysis
caused by forced ruda. or a decrease in muscle tone of a limb,
limb, dan monmonone
oneuri
uritis
tis..

Supporting Investigation:
neuroimaging, lumbar AFP management is to
puncture for, blood tests, immediately report to the
serum protein electrophoresis,
el ectrophoresis, Dinkes, supportive therapy,
paraneopl
para neoplastic
astic antibo
antibodydy symptomatic therapy for fecal
screening, electrophysiolo
el ectrophysiological
gical specimens, physiotherapy and
tests,
tests, ttens
ensilon
ilon / pro
prosti
stigmi
gmin
n tar education.
tests.
 

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