10/09/2013

Alert over Polio threat from Abroad



[Posted: Sun 06/10/2013 by Niall Hunter, Editor www.irishhealth.com]

Health authorities and the public are being urged to be on the alert in the wake of a threat of a polio spreading to Ireland from abroad.
The HSE's Health Protection Surveillance Centre (HPSC) has issued advice to prevent the spread of polio here, after wild-type polio virus (WPV1) was detected in Israel, a country frequented by many Europeans.
The HPSC has pointed out that the risk of further international spread of this polio virus from Israel to other countries is high.
In Israel at present, the health authorities have identified widespread transmission of the virus in the country, with both environmental and fecal samples testing positive for WPV1.

 To date, there have been no cases reported of the paralysis associated with polio, and it is believed that this is due to high polio vaccination rates in Israel.
However, Israel is currently monitoring the incidence of acute flaccid paralysis (AFP) and meningitis so that any polio cases can be rapidly identified. In addition, the health authorities there are stepping up their polio vaccination campaign.
AFP is a paralysis that occurs suddenly and is the most common sign of acute polio.
Europe has been polio-free since 2002. The last case of polio in Ireland was recorded in 1984.

The HPSC has urged parents to ensure that their children's vaccinations, which include the polio vaccine, are up to date. Parents of children who have missed their recommended doses should contact their GP to get the missed vaccinations. 
All travelers to and from polio-affected countries are recommended to be fully vaccinated against polio. Fully vaccinated persons aged 10 years and over traveling to endemic countries should be given a single dose of the tetanus/diphtheria/whooping cough and polio four-in-one vaccine.

The HPSC says ensuring high immunisation rates here will protect the majority of children against the polio virus if it is imported to Ireland.
It is urging GPs and practice/public health nurses to identify children who may not be aged-appropriately vaccinated and offer vaccination.
The HPSC says polio-free European countries such as Ireland are being urged to investigate all AFP cases in children under 15 to outrule polio. The HSE recently issued guidance to doctors to be on the alert for cases of this type of paralysis.
It says doctors should be alert for possible signs of polio in over 14s if they have travelled to a polio-endemic country (including Israel).

The HPSC has told doctors that as part of the investigation of hospitalized meningitis cases in people recently returned from countries where the polio virus is prevalent, stools should be tested to outrule the polio virus as a cause of meningitis.

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Erradicación de La poliomielitis

Polio Tricisilla Adaptada

March Of Dimes Polio History

Dr. Bruno

video

movie

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A 41-year-old man developed an acute illness at the age of 9 months during which, following a viral illness with headache, he developed severe weakness and wasting of the limbs of the left side. After several months he began to recover, such that he was able to walk at the age of 2 years and later was able to run, although he was never very good at sports. He had stable function until the age of 18 when he began to notice greater than usual difficulty lifting heavy objects. By the age of 25 he was noticing progressive difficulty walking due to weakness of both legs, and he noticed that the right calf had become larger. The symptoms became more noticeable over the course of the next 10 years and ultimately both upper as well as both lower limbs had become noticeably weaker.

On examination there was wasting of the muscles of upper and lower limbs on the left, and massively hypertrophied gastrocnemius, soleus and tensor fascia late on the right. The calf circumference on the right exceeded that on the left by 10 cm (figure1). The right shoulder girdle, triceps, thenar eminence and small muscles of the hand were wasted and there was winging of both scapulae. The right quadriceps was also wasted. The wasted muscles were also weak but the hypertrophied right ankle plantar flexors had normal power. The tendon reflexes were absent in the lower limbs and present in the upper limbs, although the right triceps was reduced. The remainder of the examination was normal.

Figure 1

The patient's legs, showing massive enlargement of the right calf and wasting on the left

Questions

1
What is that nature of the acute illness in infancy?
2
What is the nature of the subsequent deterioration?
3
What investigations should be performed?
4
What is the differential diagnosis of the cause of the progressive calf hypertrophy?

Answers

QUESTION 1

An acute paralytic illness which follows symptoms of a viral infection with or without signs of meningitis is typical of poliomyelitis. Usually caused by one of the three polio viruses, it may also occur following vaccination and following infections with other enteroviruses.1 Other disorders which would cause a similar syndrome but with upper motor neurone signs would include acute vascular lesions, meningoencephalitis and acute disseminated encephalomyelitis.

QUESTION 2

A progressive functional deterioration many years after paralytic poliomyelitis is well known, although its pathogenesis is not fully understood.2 It is a diagnosis of exclusion; a careful search for alternative causes, for example, orthopaedic deformities such as osteoarthritis or worsening scoliosis, superimposed neurological disorders such as entrapment neuropathies or coincidental muscle disease or neuropathy, and general medical causes such as respiratory complications and endocrinopathies.3

QUESTION 3

Investigations revealed normal blood count and erythrocyte sedimentation rate and normal biochemistry apart from a raised creatine kinase at 330 IU/l (normal range 60–120 IU/l), which is commonly seen in cases of ongoing denervation. Electromyography showed evidence of denervation in the right APB and FDI with polyphasic motor units and complex repetitive discharges, no spontaneous activity in the left calf and large polyphasic units in the right calf consistent with chronic partial denervation. Motor and sensory conduction velocities were normal. A lumbar myelogram was normal. Magnetic resonance imaging (MRI) scan of the calves is shown in figure2.

Figure 2

Axial T1 weighted MRI scan (TR 588 ms, TE 15 ms) of the calves, showing gross muscle atrophy and replacement by adipose tissue on the left, and hypertrophy of the muscles on the right, with only minor adipose tissue deposition

QUESTION 4

The differential diagnosis of the progressive calf hypertrophy is given in the box.

Causes of calf muscle hypertrophy

Chronic partial denervation

  • radiculopathy

  • peripheral neuropathy

  • hereditary motor and sensory neuropathy

  • spinal muscular atrophy

  • following paralytic poliomyelitis

    Neuromyotonia and myokymia

  • Isaac's syndrome

  • generalised myokymia

  • neurotonia

  • continuous muscle fibre activity due to: chronic inflammatory demyelinating polyradiculopathy, Guillain Barre syndrome, myasthenia gravis, thymoma, thyrotoxicosis, thyroiditis

    Muscular dystrophies

    Myositis

    Infiltration

  • tumours

  • amyloidosis

  • cysticercosis

    Link here