Updated: 5/17/2018

Poliovirus

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 Snapshot
  • A 3-year-old girl presents to a local hospital in rural Asia for sudden-onset weakness of the lower extremities over the past 2 days. Her parents report that it seems to affect the right leg more. She has not had any immunizations due to lack of access to hospitals. On physical exam, there is notable muscular atrophy of the right leg and absent reflexes on the right. Reflexes are weak on the left side. Sensation is normal bilaterally.
Introduction
  • Classification
    • poliovirus
      • a non-enveloped single-stranded (+) RNA virus
      • a picornavirus and enterovirus
    • transmission
      • fecal-oral
  • Epidemiology
    • incidence
      • endemic in areas of Asia and Africa
    • demographics
      • affects children
  • Pathogenesis
    • replicates in oropharynx and small intestines and spreads to the central nervous system via bloodstream
    • destroys the anterior horn of the spinal cord, causing lower motor neuron cell death
  • Associated conditions
    • poliomyelitis
    • meningitis
  • Prevention
    • vaccines
      • live attenuated oral polio vaccine (OPV)
        • developed by Sabin
        • may be associated with vaccine-associated paralytic poliomyelitis
        • no longer offered
      • inactivated polio vaccine (IPV)
        • developed by Jonas Salk
        • 4 doses for infants 2 months to 4-6 years
  • Prognosis
    • disease starts with preceding aseptic meningitis and progresses to flaccid paralysis
    • two-thirds of patients do not recover their strength
Presentation
  • Symptoms
    • meningitis
      • headache
      • vomiting
      • stiff neck
    • myalgias
  • Physical exam
    • systemic signs of infection
      • fever and malaise
    • lower motor neuron lesion
      • asymmetric weakness
      • asymmetric hypotonia
      • flaccid paralysis 
        • legs > arms
      • fasciculations
      • decreased or absent reflexes
      • muscle atrophy
      • normal sensory exam
Studies
  • Labs
    • cerebral spinal fluid
      • ↑ white blood cells
      • ↑ protein
      • normal glucose
      • presence of viral RNA
    • viral isolation
      • stool
      • throat
  • Making the diagnosis
    • based on clinical presentation and laboratory studies
Differential
  • Werdnig-Hoffmann disease
    • distinguishing factor 
      • both affect the anterior horns of the spinal cord but Werdnig-Hoffmann presents with symmetric weakness
  • Guillain-Barre syndrome
    • distinguishing factor
      • symmetric weakness
Treatment
  • Management approach
    • mainstay of treatment is supportive care
    • management is focused on vaccine and prevention
  • Conservative
    • physical therapy and occupational therapy
      • indication
        • all patients
    • respiratory support
      • indication
        • disease progression to respiratory system
Complications
  • Progression to respiratory failure
  • Permanent deformity
 

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