5/25/2014

Pakistan Moves to Contain Polio Virus after Travel Sanctions

 — Pakistan is moving quickly to try to contain the polio virus after the World Health Organization imposed international travel restrictions on anyone coming from the polio endemic country. Health workers in Rawalpindi are working with parents to vaccinate their children.

Pakistan has ordered mandatory polio vaccinations for anyone leaving the country’s tribal northwest where the virus is concentrated.

The World Health Organization has imposed international travel restrictions on anyone leaving Pakistan without proof of vaccination as of June 1.

Nosherwan Khan, who owns a bus depot and belongs to the Pakistan Polio Plus committee, calls the WHO decision a wake-up call.

“They have to do something, Pakistani government has to do something," said Khan. "This travel ban has come as a kind of shock to all Pakistanis, and it opened their eyes up, actually, very much."

The country has the highest number of new polio cases in the world, and Pakistanis such as Sohail Qoreshi, like most people, understand the vaccine's importance.

“Polio is an epidemic in Pakistan and spreading rapidly," said Qoreshi. "Our health workers have worked hard, they’ve gone house to house with the polio drops. Now they are providing the drops at bus stops."

Much of the country has been inoculated, leaving the virus concentrated in Pakistan’s volatile tribal regions, where Taliban militants banned vaccination efforts in 2012, leaving many beyond the reach of health workers.

World Health Organization's Nima Saeed Abid says infections will persist until vaccinations resume.

“There should be a means by all parties in conflict, or all parties who have influence in this area, to sit actually and allow vaccination of these children," said Abid. "So many children have been crippled ... due to a completely avoidable disease. I mean, health is impartial and all stakeholders should understand that."

There is evidence that polio from Pakistan has reached as far as Egypt and Israel. Now everyone here, including adults, must be vaccinated as the global effort to wipe out the disease focuses on the last few places where polio is still spreading.

Post Polio Litaff, Association A.C _APPLAC Mexico

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Erradicación de La poliomielitis

Polio Tricisilla Adaptada

March Of Dimes Polio History

Dr. Bruno

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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