DEFINITION
“AFP refers to acute onset(<4 weeks) of paralysis
of the affected limbs.”
“AFP is defined as any child aged <15 yrs who
has acute onset of flaccid paralysis for which no
obvious cause is found,or paralytic illness in a
person of any age in which polio is suspected.”
BACKGROUND AND PUBLIC HEALTH
IMPORTANCE
Reporting of all AFP cases less than 15 years of
age is mandatory in India.
All AFP cases should be investigated within 48
hours of reporting.
Two stool samples should be collected from such
cases at 24-48 hours apart intervals
The focus has shifted now to nonpolio causes of
AFP, like diphtheritic polyneuropathy, traumatic
neuritis, Guillain-Barre syndrome, rabies,
nonpolio enteroviruses and West Nile virus.
Anatomical Etiology
location
Anterior Poliovirus,nonpolio enterovirus, Japanese B
horn cell encephalitis
Dorsal root Herpes simplex virus, cytomegalovirus, rabies
ganglia
Spinal cord Acute transverse myelitis, parasitic infestation
(Schistosoma, Cysticercus, Echinococcus), space
occupying lesions, anterior spinal artery syndrome,
trauma, postcardiovascular surgery vascular
complications
Radicles and Guillain-Barré syndrome, chronic inflammatory
peripheral demyelinating polyneuropathy, HIV infection or associated
nerves opportunistic infections or complications, vitamin B₁2
deficiency, nucleoside antiretroviral agents, hepatitis B,
diphtheria, rabies, tick bite, borreliosis, heavy metals,
chemotherapeutic agents, organic solvents including glue
sniffing, critical illness, hypokalemic and thyrotoxicity
Neuromuscu Myasthenia crisis, organophosphorous poisoning,
lar junction drugs(aminoglycoside, phenytoin), botulism,
Elapidae snake envenomation, and critical illness
Muscle Polymyositis,Systemic lupus erythematous, mixed
connective tissue disorder, viral(HIV, nonpolio
enteroviruses, human T cell lumphotropic viruses),
toxoplasmosis, Lyme disease, trichinosis
Clinical features of conditions causing
acute flaccid paralysis
Site Clinical features Conditions
Muscles Neck, limb girdle, proximal Myoglobinuric myopathy,
muscles affected hypokalemic paralysis. toxic
Possible cardiomyopathy paralysis, myopathy of
Occasional respiratory muscle intensive care
involvement
Neuromuscu Cranial, limb girdle and proximal Myasthenia gravis
lar junction muscles Botulism, hypermagnesemia
May affect respiratory muscles
Autonomic signs (presynaptic)
Fatigability (post synaptic)
Peripheral Weakness: distal, symmetrical, Guillain-Barré syndrome
nerve sensory Diphtheric neuropathy
May have associated autonomic Porphyria, lead neuropathy
signs Hypophosphatemia,
May involve cranial nerves. cobalamin deficiency
Deep tendon reflexes
reduced/lost early
Anterior Predominantly motor signs, Poliomyelites
horn cells hyporeflexia Other enteroviruses
Sensory symptoms uncommon
Often asymmetric
CLINICAL MANIFESTATIONS
Fever and respiratory symptoms (cough,
rhinorrhea, pharyngitis, or asthmalike illness).
Vomiting or diarrhoea.
Acute weakness.
Headache, neck stiffness, or recurrence of fever.
Meningism
Limb weakness
Pain in the affected limb(s), neck, or lower back.
Flaccid weakness
Severe weakness in affected upper limb(s) and
normal strength in the lower limbs
Affected limbs become hyporeflexic or
areflexic.
Weakness can also affect the neck, trunk,
diaphragm, or other respiratory muscles.
Bulbar and facial weakness, and, less commonly,
extraocular muscle weakness.
CLINICAL ASSESSMENT
Onset of paralysis
Progression of paralysis
Topography of paralysis
Sensory features
Deep tendon reflexes
Bladder bowel involvement
Fever at onset of paralysis
Etiology specific features
INVESTIGATIONS
Faecal specimens for viral culture
Magnetic resonance imaging
Electrophysiology
Cerebrospinal fluid examination
Serum creatine phosphokinase
Lyme's serology.
Nerve Conduction studies and Electro
Myography(EMG)
Detect and manage bulbar weakness
Evaluate for cardiovascular instability
To rule out a spinal compression (traumatic, intraspinal
collections)
INITIAL APPROACH TO A CHILD
WITH AFP
Respiratory care
Bulbar weakness detection and
management
Managing cardiovascular instability
Rule out spinal cord pathology
TREATMENT
Initial approach to a child with AFP.
This category includes treatment options, which are
curative.
Intravenous immunoglobulin (IVIG): Indicated in GBS
and myasthenic crises (2 g/kg/day, divided over 4-5
days in once daily dosage).
Pulse methylprednisolone therapy 30 mg/kg/day
(maximum: 1 g) for transverse myelitis.
Anti-snake venom in suspected cases of envenomation.
Intravenous potassium for hypokalemia.
SUPPORTIVE CARE
Prevention of bedsores
Bladder and bowel care
Nutrition
Physical and occupational
therapy
MANAGEMENT
Restriction
If polio is suspected, polio non-immune health care
workers should not care for the patient.
Intubation and ventilation
Supplemental hydration and
nutrition.
CONCLUSION
RELATED RESEARCH STUDY
1.Acute Flaccid Paralysis in Children:
Active Surveillance for Poliomyelitis
A study was conducted to determine the
epidemiologic, clinical and etiologic factors
associated with acute flaccid paralysis(AFP)
in children and their relationship to
concurrent childhood immunizations.
Eleven pediatric tertiary care hospitals across
Canada participating in the Immunization
Monitoring Program, ACTive (IMPACT), of the
Canadian Pediatric Society, conducted active
surveillance for cases of AFP. Children with AFP
admitted to any of the centres were identified by
intensive case surveillance on the wards, and
thorough searches through hospital records and
coded discharge summaries. Outcome measures
included age, clinical features, immunization
history, diagnostic investigations, treatment, and
final etiologic diagnosis.
The total number of cases of AFP was 122
children with a mean of 2.6 cases per hospital per
year. Age distribution was random. Most children
(94%) had no previous neurological history, but
the majority (75%) had a preceding non-
neurological illness. Immunization history was
complete for 88 (72%) children. The majority,
94(77%) cases of AFP, were diagnosed with
Guillan-Barre syndrome. An etiological diagnosis
for AFP was established in 31 (25%) children.
There were no cases of vaccine-associated
paralysis and no cases of poliomyelitis. A five
year multicentre hospital-based study reveals that
the most frequent cause of childhood AFP is
Guillain-Barre syndrome followed by transverse
myelitis. There were no cases of AFP associated
with poliomyelitis or vaccination. Active
surveillance should continue until global
eradication of poliomyelitis is acheived.
2. Acute flaccid myelitis in childhood: a
retrospective cohort study
A retrospective cohort study study was conducted
in Eight children (six females) aged 3 months to 8
years (median age 5 years) met case criteria.
Initial symptoms were pain (n = 7) followed by
limb weakness with hypotonia (n = 8). Flaccid
paralysis occurred in only three patients.
Two had cranial nerve dysfunction. Magnetic
resonance imaging of the spinal cord
demonstrated grey matter involvement particularly
affecting the anterior cord, with longitudinally
extensive changes in three children. Cerebrospinal
fluid examination showed pleocytosis in six
children with raised cerebrospinal fluid protein in
five. Nerve conduction and electromyography
findings were consistent with a motor
neuronopathy.
Residual deficits were common, with moderate to
severe weakness seen in five patients. Median
follow-up was 28 months (range 17–108 months,
30.4 patient years in total).
Acute flaccid myelitis is an uncommon condition
in childhood with a high rate of significant long-
term morbidity. AFM should be considered in
children presenting with acute limb pain and
weakness.
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